Oral submucous fibrosis--a new treatment regimen

Interventions for managing oral submucous fibrosis

BACKGROUND

Oral submucous fibrosis (OSF) is a chronic disease of the oral cavity that causes progressive constriction of the cheeks and mouth accompanied by severe pain and reduced mouth opening. OSF has a significant impact on eating and swallowing, affecting quality of life. There is an increased risk of oral malignancy in people with OSF. The main risk factor for OSF is areca nut chewing, and the mainstay of treatment has been behavioural interventions to support habit cessation. This review is an update of a version last published in 2008.

OBJECTIVES

To evaluate the benefits and harms of interventions for the management of oral submucous fibrosis.

SEARCH METHODS

We used standard, extensive Cochrane search methods. The latest search date was 5 September 2022.

SELECTION CRITERIA

We considered randomised controlled trials (RCTs) of adults with a biopsy-confirmed diagnosis of OSF treated with systemic, locally delivered or topical drugs at any dosage, duration or delivery method compared against placebo or each other. We considered surgical procedures compared against other treatments or no active intervention. We also considered other interventions such as physiotherapy, ultrasound or alternative therapies.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Our primary outcomes were 1. participant-reported resumption of normal eating, chewing and speech; 2. change or improvement in maximal mouth opening (interincisal distance); 3. improvement in range of jaw movement; 4. change in severity of oral/mucosal burning pain/sensation; 5.

ADVERSE EFFECTS

Our secondary outcomes were 6. quality of life; 7. postoperative discomfort or pain as a result of the intervention; 8. participant satisfaction; 9. hospital admission; 10. direct costs of medication, hospital bed days and any associated inpatient costs for the surgical interventions. We used GRADE to assess certainty of evidence for each outcome.

MAIN RESULTS

We included 30 RCTs (2176 participants) in this updated review. We assessed one study at low risk of bias, five studies at unclear risk of bias and 24 studies at high risk of bias. We found diverse interventions, which we categorised according to putative mechanism of action. We present below our main findings for the comparison 'any intervention compared with placebo or no active treatment' (though most trials included habit cessation for all participants). Results for head-to-head comparisons of active interventions are presented in full in the main review. Any intervention versus placebo or no active treatment Participant-reported resumption of normal eating, chewing and speech No studies reported this outcome. Interincisal distance Antioxidants may increase mouth opening (indicated by interincisal distance (mm)) when measured at less than three months (mean difference (MD) 3.11 mm, 95% confidence interval (CI) 0.46 to 5.77; 2 studies, 520 participants; low-certainty evidence), and probably increase mouth opening slightly at three to six months (MD 8.83 mm, 95% CI 8.22 to 9.45; 3 studies, 620 participants; moderate-certainty evidence). Antioxidants may make no difference to interincisal distance at six-month follow-up or greater (MD -1.41 mm, 95% CI -5.74 to 2.92; 1 study, 90 participants; low-certainty evidence). Pentoxifylline may increase mouth opening slightly (MD 1.80 mm, 95% CI 1.02 to 2.58; 1 study, 106 participants; low-certainty evidence). However, it should be noted that these results are all less than 10 mm, which could be considered the minimal change that is meaningful to someone with oral submucous fibrosis. The evidence was very uncertain for all other interventions compared to placebo or no active treatment (intralesional dexamethasone injections, pentoxifylline, hydrocortisone plus hyaluronidase, physiotherapy). Burning sensation Antioxidants probably reduce burning sensation visual analogue scale (VAS) scores at less than three months (MD -30.92 mm, 95% CI -31.57 to -30.27; 1 study, 400 participants; moderate-certainty evidence), at three to six months (MD -70.82 mm, 95% CI -94.39 to -47.25; 2 studies, 500 participants; moderate-certainty evidence) and at more than six months (MD -27.60 mm, 95% CI -36.21 to -18.99; 1 study, 90 participants; moderate-certainty evidence). The evidence was very uncertain for the other interventions that were compared to placebo and measured burning sensation (intralesional dexamethasone, vasodilators). Adverse effects Fifteen studies reported adverse effects as an outcome. Six of these studies found no adverse effects. One study evaluating abdominal dermal fat graft reported serious adverse effects resulting in prolonged hospital stay for 3/30 participants. There were mild and transient general adverse effects to systemic drugs, such as dyspepsia, abdominal pain and bloating, gastritis and nausea, in studies evaluating vasodilators and antioxidants in particular.

AUTHORS' CONCLUSIONS

We found moderate-certainty evidence that antioxidants administered systemically probably improve mouth opening slightly at three to six months and improve burning sensation VAS scores up to and beyond six months. We found only low/very low-certainty evidence for all other comparisons and outcomes. There was insufficient evidence to make an informed judgement about potential adverse effects associated with any of these treatments. There was insufficient evidence to support or refute the effectiveness of the other interventions tested. High-quality, adequately powered intervention trials with a low risk of bias that compare biologically plausible treatments for OSF are needed. It is important that relevant participant-reported outcomes are evaluated.

Platysmal Myocutaneous Flap for Intra Oral Defects:Is It an Underutilized Option? Our Experience of 10 Cases

Various methods of reconstruction are available for reconstructing oral cancer defects, but all of them have their inherent drawbacks. The superiorly based platysma myocutaneous flap is a common reconstruction option for intra-oral defects following oral cancer resections. We present our results of using platysmal flaps in reconstructing intraoral defects following oral cavity cancer resection in our 7 patients along with resection of three cases of premalignant conditions of oral cavity. All the patients were males of age ranging from 24 to 42 years and diagnosed as squamous cell carcinoma of oral cavity stage I and II were included in this study.Of 10 patients eight had no postoperative complications. One patient developed partial skin loss of neck donor site, which was managed conservatively. Other patient had complete flap loss which healed with secondary intention. We recommend this flap as incision is always away from the face, the scars are hidden beneath collars and the patients are very comfortable with good cosmetics and functional outcomes.\.

A Clinicopathological Study of OSMF to Evaluate the Response After Treatment with Intralesional Steroid Versus Intralesional Steroid Plus Hyaluronidase

Oral submucous fibrosis (OSMF) is a chronic debilitating and a well-recognized potentially malignant condition of the oral cavity, sometimes involving oropharynx associated with trismus and burning sensation. Apart from medical management and counselling, local injection of hyaluronidase mixed with triamcinolone acetonide has been used at our centre for the last 20 years with satisfactory clinical results and without any significant side effects. The problem with the treatment was that the doses and duration of treatment has not been standardized. Therefore, in this study, authors aim to evaluate and compare the efficacy of Triamcinolone alone versus Triamcinolone acetonide plus Hyaluronidase at weekly interval and improvement in Clinical and Histopathological staging of disease after 6 weeks of treatment. This study was conducted in Department of Otorhinolaryngology & Head Neck Surgery, with a total sample of 80 participants divided into two Groups, group A received Inj. Triamcinolone acetonide and group B received Inj. Triamcinolone Acetonide and Hyaluronidase 1500 IU at weekly interval. Pre-treatment and post-treatment clinical and histopathological profile of the patients were recorded and analyzed using SPSS 16 software. According to pre-treatment status, the proportion of clinical grades I, II and III were found in proportion 12.5%, 18.8% and 15.0% respectively. No significant difference was found in proportion of various grades between the groups (p = 0.388). At post treatment, the grading was reduced with changed proportion of grades I, II and III cases as 33.8%, 41.3% and 7.5% respectively. There was no significant difference in proportion of various grades between the groups (p = 0.681). Further, the intragroup comparison showed significant improvement Pre to post in group A (p = 0.002), Group B (p < 0.001) and overall, as well (p < 0.001). The inj. Triamcinolone acetonide and Inj. Hyaluronidase showed a better improvement on post treatment histopathological grading although the difference between the two groups was not significant statistically.

Oral Submucous Fibrosis: A Review of the Current Concepts in Management

Oral submucous fibrosis (OSMF) is a precancerous disorder of the submucosa that causes inflammation and progressive fibrosis, leading to pronounced stiffness and trismus. Chewing betel nuts is a significant risk factor for OSMF in India. Arecoline from betel nuts and copper, which causes fibroblast dysfunction and the development of fibrotic bands, are the main components of betel quid. OSMF is distinguished by fibrosis in the submucosal region, which affects the majority of the oral cavity and results in advanced lockjaw due to rigidity in the lips, pharynx, cheeks, and upper third of the oesophageal canal, which progresses to dysphagia. The prevalence of OSMF is rising, particularly among younger generations, as more commercially available areca nut products like gutka (chewing tobacco) and others are being introduced. The severity of OSMF develops as the practice continues and is permanent. It also persists even after chewing has been stopped. The hallmark of oral submucous fibrosis (OSF) is abnormal collagen deposition. It is a precancerous condition and progresses to malignant tumours. Symptoms include ulcers, xerostomia, submucous fibrosis, burning sensation, and a reduction in mouth opening. Each of these drastically reduces the patient's quality of life. In the past, many treatment modalities have been tried but none of them has resulted in a cure for the disease. The primary focus of the treatment is to reduce the signs and symptoms so that the patient can have a better quality of life. Along with principles, conservative, medical, and surgical management issues have also been covered.

Management of Oral Sub Mucous Fibrosis Using Three Different Flaps: Superficial Temporal, Nasolabial Flap, Buccal Fat Pad Flap Along with Active Physiotherapy- A Comparative Study

To assess the efficacy of different flaps along with active physiotherapy for comprehensive management of OSMF. A total of 33 patients of oral submucous fibrosis were admitted and surgically treated. All patients were diagnosed with bilateral oral submucous fibrosis of buccal mucosa. All the patients had advanced oral sub mucous fibrosis with interincisal distance less than 20 mm. Eleven patients were treated with buccal pad of fat, eleven with nasolabial flap and eleven patients were treated with temporo-parietal fascia flap. Physiotherapy was started from the 5th postoperative day and the patients were followed regularly for one year to measure maximum interincisal distance. There was a significant corelation between post-operative mouth opening and regular physiotherapy, exercise and quitting of the habit irrespective of type of reconstruction flap used. On the basis of the result obtained from this study, significant improvement in mouth opening was seen in patients who performed aggressive physiotherapy irrespective of the flap used. Thus we conclude along with the surgical treatment, post-operative physiotherapy and cessation of habit are of equal importance for good prognosis in OSMF patients.

Study of Efficacy of Intraoral Submucosal Injections of Corticosteroids and Placentrex in the Management of Oral Submucous Fibrosis

In a country such as India, popularly known for its rich diversity and traditions, chewing tobacco and its many other forms is a commonly practised entity. The resultant of this leads to oral submucous fibrosis (OSMF) which causes permanent morbidity in the form of trismus and also can lead to potential possibility of oral cancer. Intra oral injections of steroids such as hyaluronidase and placentrex have been postulated by many studies. But this study was done to evaluate the efficacy of both these commonly used treatment modalities. A 1 year hospital based study was performed over 30 patients diagnosed to be having oral submucosal fibrosis. They were randomly given injection hyaluronidase and injection placentrex. In addition to this, routine haemogram was done and the inter incisor distance was measured before and after the treatment along with histopathological study of the oral lesions. With a prevalence of 0.31%, the males out numbered females. Majority of the patients were in their third decade. All patients chewed tobacco in one or the other form and 90% of them presented with burning sensation in the mouth. The mean inter incisor distance in our patients was 3.1%. A third of the cases were anaemic and two thirds had an elevated erythrocyte sedimentation rate and serum globulin level. More than half the cases had an elevated absolute eosinophil count. All 30 biopsy specimens showed atrophic oral mucosa with subepithelial dense collagenised fibrous tissue. The group of patients who were treated with injection placentrex showed slightly better results than corticosteroids. The results were not statistically significant although clinically they were noteworthy. Being a silent, chronic disease, oral submucosal fibrosis affects the most productive population fraction of our country causing morbidity and also acts as precursor for oral cancer. Since the etiological agent is chewing areacnut in one form or the other, considerable efforts have to be made in sensitizing the workforce of the nation at the community level in understanding the ill effects of chewing tobacco. Understanding the associated conditions such as anaemia, elevated erythrocyte sedimentation rate, serum globulins and absolute eosinophil count should prompt the otolaryngologist in treating these patients holistically. Though injection placentrex yielded better improvement in the inter incisor distance, the results with steroid injection was also comparable with no statistical significance. Hence, keeping the premalignant nature of the disease, screening the patients promptly and treating them on time would lead to considerable reduction in the morbidity caused by the disease. Coupled with health education, the results could be even more encouraging.

Comparative Efficacy of Interventions for the Management of Oral Submucous Fibrosis: A Systematic Review and Network Meta-Analysis

Introduction: Oral submucous fibrosis (OSMF) is a chronic premalignant condition and is characterized by fibroblastic change of lamina propria and stiffness of oral mucosa. Though there are several treatment options available, the best agent is not yet identified. This study assessed the comparative efficacy and safety of medical interventions in the management of OSMF. Methods: A systematic review was performed to identify randomized controlled trials (RCTs) that compared the efficacy of interventions for OSMF with each other, or placebo. A network meta-analysis was performed, and the interventions were ranked according to their efficacy based on the surface under the cumulative ranking. (PROSPERO Registration no: CRD42021255094). Results: Thirty-two RCTs comprising 2063 patients were eligible for quantitative analysis. In terms of therapeutic efficacy in the improvement of mouth opening Oxitard, a herbal formulation was ranked as the most efficacious agent, [MD, 10.29 (95%CI 6.34–14.25)] followed by combination therapy of Lycopene with corticosteroids and hyaluronidase [MD, 7.07 (95%CI 1.82–12.31)]. For improvement of burning sensation aloe vera was ranked first [MD, 6.14 (95%CI 4.58–7.70)] followed by corticosteroids with antioxidants [MD, 6.13 (95%CI 4.12–8.14)] and corticosteroids in combination with hyaluronidase with antioxidants [MD, 5.95 (95%CI 3.79–8.11)]. In terms of safety, most of the drugs were reported to cause mild adverse effects only. Significant inconsistencies could be identified in the analysis for both the outcomes assessed and were further explored. Conclusions: Our study highlighted the potential efficacy of several agents over placebo in the improvement of mouth opening and burning sensation in OSMF patients. However, the RCTs lacked methodological soundness. Well-designed studies with a larger number of participants with a rigorous randomization process and stringent methodology are recommended to strengthen the results obtained, which may help to construct a clinical guideline for OSMF management.

Methylprednisolone and Hyaluronic Acid versus Each Agent Alone to Control Complication of Impacted Wisdom Removal

Introduction. Extraction of impacted molars is commonest operation in oral cavity and associated with complications disturbing patient’s quality of life. Hyaluronic acid is a nontoxic agent recommended for wound management due to its anti-inflammatory effects. Also, methylprednisolone sodium is used to reduce pain and edema. The aim this study was to compare the effect of combined use of corticosteroid and hyaluronic acid versus each agent alone in controlling postextraction complications of impacted mandibular third molars. Materials and Methods. This prospective randomized trial included patients suffering from impacted mandibular third molar. Patients were divided into four groups. Group I, control, and group II received methylprednisolone sodium succinate injection preoperatively, group III received hyaluronic acid applied in extraction socket, and group IV received preoperative methylprednisolone sodium succinate injection and topical hyaluronic acid in the socket. All patients were evaluated preoperatively and postoperative day to assess swelling, pain, mouth opening, and total analgesic dose. Results. Group IV showed insignificant edema along the study period, and other groups showed significant edema on third postoperative day that improved on seventh postoperative in group II and III and tenth postoperative day in group I. Significant decreased mouth opening occurred on second postoperative day in group I, while in other groups, it occurred in third postoperative day. Significant improvement occurred on seventh postoperative day in all groups except in group I which occurred on tenth postoperative day. There was less pain and analgesic dose reported in group IV than other groups. Conclusion. Combined use of methylprednisolone sodium succinate and hyaluronic acid significantly decrease postoperative complications than using each agent alone.

In-vitro analysis on the potential use of dental pulp mesenchymal stem cells on arecoline-induced oral epithelial cells

To assess the protective role of the secretome of dental pulp mesenchymal stem cells on arecoline-induced epithelial-mesenchymal transition and senescence on epithelial cells of the oral mucosa. Effect of varying concentrations of arecoline extract and dental pulp mesenchymal stem cell condition media (DPSC-CM) were noted on oral mucosal epithelial cells. MTT assay, Annexin V-FITC/PI assay, and the quantitative gene expressions of BCL2, PUMA, BAD, BAX, CASP3, CASP9, CASP12, TGFB1, CST3, COL1A2, COL3A1, TIMP1, TIMP2, CDH1, and CDH2 were assessed. Oral mucosal epithelial cells exposed only to the arecoline were the control. 50% and 100% DPSC-CM decreased apoptosis-related gene expression in the cells exposed with 25 μM arecoline compared to the control. 50% DPSC-CM attenuated the expression of all fibrotic genes and EMT-related genes. 20% and 100% DPSC-CM showed differential effects on fibrotic and EMT-related genes. DPSC-CM inhibited apoptosis, and attenuated expression of fibrotic and EMT-related genes on arecoline treated human oral epithelial cells.

Evaluating the Oral-Health-Related Quality of Life of Oral Submucous Fibrosis Patients before and after Treatment Using the OHIP-14 Tool

The objective of the present study was to assess the oral-health-related quality of life (OHRQoL) of oral submucous fibrosis (OSMF) patients before and after standard treatment. A convenient sampling technique was used to recruit the clinically diagnosed patients of OSMF (n = 130). Based on the medical treatment, the patients were randomly divided into two study groups (group A and B). The group A patients received submucosal intralesional injections of dexamethasone (2 mL; 4 gm/mL), while group B patients received hyaluronidase (1500 IU). Both the group A and B patients received respective medical therapy biweekly for a period of five weeks. At the follow up visit (6 months), the impact of treatment on OHRQoL was assessed using the Oral Health Impact Profile-14 (OHIP-14). Data were analyzed by a chi-square test for quantitative variables and an independent t-test for qualitative variables. The comparison of all clinical parameters before and after treatment was performed by a paired t-test. The results after treatment showed that there was a significant improvement in all domains of OHIP-14 (p = 0.001) except psychological disability (p = 0.243). In addition, the OHRQoL of patients was significantly improved following the treatment.

Nanoparticulate strategies for the delivery of miRNA mimics and inhibitors in anticancer therapy and its potential utility in oral submucous fibrosis

MicroRNAs (miRNAs) are naturally occurring noncoding RNAs with multiple functionalities. They are dysregulated in several conditions and can serve as disease biomarkers, therapeutic targets and therapeutic agents. Translation of miRNA therapeutics to the clinic poses several challenges related to the safe and effective delivery of these agents to the site of action. Nanoparticulate carriers hold promise in this area by enhancing targeting efficiency and reducing off-target effects. This paper reviews recent advances in the delivery strategies of miRNAs in anticancer therapy, with a focus on lipid-based, polymeric, inorganic platforms, cell membrane-derived vesicles and bacterial minicells. Additionally, this review explores the potentiality of miRNAs in the treatment of oral submucous fibrosis, a potentially premalignant condition of the oral cavity with no definitive treatment to date.

Potential Application of an Aqueous Extract of Tinospora Cordifolia (Thunb.) Miers (Giloy) in Oral Submucous Fibrosis-An In Vitro Study

The in vitro antifibrotic activity of Tinospora cordifolia (Thunb.) Miers (giloy) was assessed to explore its potential for the management of oral submucous fibrosis. Epithelial cells dissociated from the tissue obtained from histopathologically normal oral mucosa during surgical extraction of third molars were cultured and fibrosis was induced by TGF-β1 in the oral keratinocytes. Cell viability was assessed by MTT and comparative gene expression analysis was carried out in the fibrosis-induced oral keratinocytes treated with various concentrations of Tinospora cordifolia extract (TcE) for matricellular protein-related gene expression. Concentrations of 0.5 µg/mL and 1 µg/mL TcE demonstrated a significant reduction in the expression of CTGF, SERPINE1, COL1A1, FN1, MMP1, MMP2, MMP3, and TIMP2 and an increase in the expression of PLAU, COL3A1, TIMP1, and TIMP3. Although TcE was found to reduce the expression of several fibrotic genes and increase the expression of antifibrotic genes, a varied effect was found, causing increased expression of COL3A1 and decreased expression of TIMP2 on TGF-β1-induced human buccal epithelial cells. However, further studies are warranted to assess the exact mechanism of antifibrotic activity and its clinical applications.

Research Achievements of Oral Submucous Fibrosis: Progress and Prospect

Oral submucous fibrosis (OSMF) is a kind of chronic, insidious disease, and it is categorized into potentially malignant disorders (PMD), which poses a global and regional problem to public health. It is considered to be a multifactorial disease, such as due to areca nut chewing, trace element disorders, and genetic susceptibility. However, there is still no unanimous conclusion on its pathogenesis, diagnosis, and treatment strategies. Hence, this article provides a comprehensive review and prospect of OSMF research, providing scholars and clinicians with a better perspective and new ideas for the research and treatment of OSMF.

Effect of trans retinoic acid on patients with oral submucous fibrosis-randomized single-blind monocentric study

Various treatment modalities have been practiced for the suppression of premalignant conditions such as oral submucous fibrosis (OSMF) to prevent their differentiation into malignant lesions. Conventional treatment includes steroids, enzymes like hyaluronidase, trypsin, chymotrypsin and placental extracts which are advocated intralesionally and oral drugs like carotenoids, alpha lipoic acid, lycopene, vitamins, microelements and tea pigments have also been advocated.In this study, a total number of 30 patients with OSMF were taken and randomly divided into two groups with 15 patients each according to Khanna and Andrade group of classification 1995. Group 1 (test group) received the test drug Tretiome 20 mg, whereas Group 2 (control group) received an antioxidant lycopene 20 mg/day for a period of 1 month and the effect of the therapy with the changes in the symptoms was recorded every 1 week, 15 days and 30 days of follow-up. The result of this study showed an improvement in the mouth opening of the patients of test Group with a significant decrease in the burning sensation as compared to the control group (P < 0.05). Xerostomia and headache were the two most commonly seen side effects which were reported in the patients of the test group, of which headache was associated with the withdrawal symptom of habit cessation and xerostomia was taken care by increase in hydration.

What is the Optimal Reconstructive Option for Oral Submucous Fibrosis? A Systematic Review and Meta-analysis of Buccal Pad of Fat Versus Conventional Nasolabial and Extended Nasolabial Flap Versus Platysma Myocutaneous Flap

Background

To systematically review the reconstructive options for oral submucous fibrosis utilizing buccal pad of fat versus conventional nasolabial and extended nasolabial flap versus platysma myocutaneous flap.

Objective

The succeeding systematic review and meta-analysis addresses the following question, what is the optimal reconstructive option for oral submucous fibrosis?

Study Design

A systematic electronic and manual database search revealed five relevant articles comparing buccal fat pad, nasolabial flap and platysma myocutaneous flap as reconstructive options in oral submucous fibrosis.

Methods

A total of 1538 articles were found across PubMed, Cochrane and clinical trials.gov. Only five relevant articles were selected for the study. Quality assessment of the selected studies was executed by Newcastle-Ottawa scale. Statistical software RevMan (Review Manager [Computer program], version 5.3, Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration, 2014) was used for meta-analysis. Differences in means and risk ratios were used as principal summary measures. The overall estimated effect was categorized as significant where p < 0.05.

Results

Three of the five studies selected favoured buccal fat pad over nasolabial flap owing to its ease of harvest and lesser number of post-operative complications. One study favoured nasolabial flap because of the progressive increase in mouth opening and bulk of the tissue obtained for reconstruction. A single study favoured platysma flap over nasolabial flap although no difference was obtained in mouth opening, owing its excellent tissue bulk, fewer complications compared to the nasolabial flap.

Conclusion

Definitive conclusions cannot be drawn as there are number of limitations in the studies included. However, a general consensus has been towards favouring buccal fat pad over nasolabial flap. The platysma flap owing to its excellent tissue bulk and fewer complications can be considered as an alternative when dealing with defects which are challenging to reconstruct with the buccal fat pad.

Hypothesizing the therapeutic potential of mesenchymal stem cells in oral submucous fibrosis

Oral submucous fibrosis is the direct consequence of a sustained pro-inflammatory environment characterized by excessive collagen deposition causing tissue fibrosis, and progressive degeneration of vital structures including muscle. The pathogenesis of oral submucous fibrosis is largely mediated by the pro-inflammatory, pro-fibrotic cytokines, excessive oxidative stress, abnormal angiogenesis, and epithelial to mesenchymal transition. Mesenchymal stem cells largely known for their regenerative potential have shown to have an immunomodulatory, anti-fibrotic, anti-oxidative, and angiogenic potential. Thus, mesenchymal stem cells, when introduced in an oral submucous fibrosis micro-environment, could potentially counter the progressive fibrosis. The present hypotheses discuss the various pathogenic aspects of oral submucous fibrosis and the properties of mesenchymal stem cells which could aid in halting the disease progression.

Efficacy of hyaluronidase combined with corticosteroids in treatment of oral submucous fibrosis: A meta-analysis of randomized controlled clinical trials

OBJECTIVE

This meta-analysis was performed to systematically evaluate the efficacy of hyaluronidase combined with corticosteroids compared with other drugs in improving maximum mouth opening and alleviating the burning sensation in patients with oral submucous fibrosis (OSF).

METHODS

PubMed, Embase, Web of Science and the Cochrane Library were searched. RevMan 5.3 software was used for the meta-analysis.

RESULTS

Six studies involving 244 patients with OSF were analysed. No significant difference in improvement of maximum mouth opening was found between the hyaluronidase and control groups (lycopene, pentoxifylline, aloe vera, dexamethasone, Turmix [curcumin + piperine] and isoxsuprine) at 1 month (mean difference [MD]: 0.32, 95% confidence interval [CI]: -0.92-1.56, P = .61, I²  = 57%), 2 months (MD: 0.49, 95% CI: -0.14-1.12, P = .12, I²  = 41%) or 3 months (MD: 0.40, 95% CI: -1.08-1.87, P = .60, I²  = 92%). Additionally, no statistically significant difference was found in alleviation of the burning sensation between the two groups at 1 month (MD: 0.54, 95% CI: -0.62-1.71, P = .36, I²  = 0%), 2 months (MD: 0.53, 95% CI: -0.85-1.91, P = .45, I²  = 0%) or 3 months (MD: 0.64, 95% CI: -1.07 to 2.35, P = .46, I²  = 0%).

CONCLUSIONS

According to this meta-analysis, weak evidence indicates that hyaluronidase combined with corticosteroids has no additional clinical benefit over control drugs (lycopene, pentoxifylline, aloe vera, dexamethasone, Turmix and isoxsuprine) in improving maximum mouth opening and alleviating the burning sensation in patients with OSF. Therefore, more high-quality, multi-centre randomized controlled trials with larger samples are needed to further assess the efficacy of hyaluronidase combined with corticosteroids in the treatment of OSF.

Versatility of Buccal Pad Fat and Temporoparietal Fascia Flap in Surgical Management of Oral Submucous Fibrosis

The various surgical procedures for surgical management of oral submucous fibrosis (OSMF) include excision of fibrous bands with or without grafts or flaps. Materials for attempted grafting included skin, placental grafts, and artificial dermis. Materials that can be used as flaps are tongue flaps, buccal fat pad, greater palatine pedicle flaps nasolabial flaps, anterolateral thigh flap, radial forearm flap, and temporalis fascia flap. The temporoparietal flap is ultrathin surgically single layer fibrovascular sheet with high vascularity, flexibility, pliability, and versatility. Ten cases with Grade III and Grade IV OSMF with 5 patients planned for reconstruction with buccal fat pad and 5 patients planned for temporoparietal fascia flap (TPFF) after surgical resection of fibrotic bands were undertaken for the study. After 7 days, both flaps healed nicely with complete epithelization of the two flaps occurred. There were no complications except for hyperplasia of TPFF that covered the defect. Postoperative histopathological examination of hyperplastic temporoparietal fascia revealed well-differentiated squamous-cell carcinoma in one patient and in another case, there was failure of TPFF. Both buccal pad fat and TPFF are reliable for the reconstruction of buccal mucosal defects in surgical management of OSMF.

Efficacy of Salvia miltiorrhiza injection combined with steroids in the treatment of oral submucous fibrosis: A meta-analysis of randomized controlled trials

BACKGROUND

This study was performed to systematically review the efficacy of Salvia miltiorrhiza injection combined with steroids in the treatment of oral submucous fibrosis.

METHODS

We searched 9 databases: Web of Science, PubMed, Medline, EBSCO, Embase, The Cochrane Library, WanFang Data, the China National Knowledge Infrastructure (CNKI), and Chinese Scientific Journals Full-text Database (VIP). Randomized controlled trials were collected to study the treatment of oral submucous fibrosis by S miltiorrhiza injection combined with steroids. Each database was searched from inception to November 2018. RevMan 5.3 software was used for the meta-analysis.

RESULTS

In total, 13 randomized controlled trials involving 1190 patients were included. The results of the meta-analysis showed that compared with conventional treatment, S miltiorrhiza injection combined with steroids could significantly increase the maximal mouth opening [mean difference (MD), 0.23; 95% confidence interval (CI), 0.16-0.30; P <.0001], decrease the oral mucosal lesion area (MD, -1.35; 95% CI, -2.46 to -0.25; P = .02), improve the subjective symptom burning sensation (MD, -0.77; 95% CI, -1.38 to -0.16; P = .01), and reduce adverse drug reactions (risk ratio, 0.27; 95% CI, 0.14-0.49; P <.0001).

CONCLUSIONS

The results of this meta-analysis from current evidence showed that compared with conventional treatment, S miltiorrhiza injection combined with steroid could significantly improve the maximal mouth opening and the subjective symptom burning sensation as well as decrease the oral mucosal lesion area without increasing adverse effects.

Oral Submucous Fibrosis: A Review on Etiopathogenesis, Diagnosis, and Therapy

Oral submucous fibrosis (OSF) is characterized by abnormal collagen deposition. It is a precancerous disorder and transforms into a malignant tumor in 1.5–15% of all cases. Symptoms include submucous fibrosis, ulceration, xerostomia, a burning sensation, and restricted mouth opening. All of these greatly interfere with patient quality of life. The present review introduces OSF from a molecular perspective and summarizes what is known about its underlying mechanisms, diagnostic biomarkers, and therapeutic interventions. In addition to the aggressive treatment of OSF, its prevention is also important. Future research should, therefore, focus on improving the oral health literacy of the patients susceptible to OSF.

Efficacy of Prednisolone Mouthwash in Management of Grade III Oral Submucous Fibrosis: A Newer Drug Regimen

Introduction

This clinical randomized controlled trial evaluates the effectiveness of prednisolone mouthwash as a treatment modality for moderately advanced cases of oral submucous fibrosis.

Materials and Method

Sixty-four patients were enrolled for the study and randomized into two groups (n = 32 in each group). The experimental group was treated with prednisolone mouthwash and antioxidant capsule as per GDCH Nagpur protocol, and control group was treated with antioxidant capsule only. The primary outcome variables were interincisal mouth opening, burning sensation, and recurrent ulceration. Clinical responses were obtained at the time of the allocation, at 1, 3, 6, and 9 months into the intervention, and 6 months thereafter.

Results

The average increased mouth opening achieved was 10.46 mm (p < 0.5) in group A (experimental group) and only 1.04 mm (p < 0.5) mm in group B (control group). In addition, there was a significant difference in relief of burning sensation and recurrent ulceration. Relief of burning sensation and recurrent ulceration was within 12.81 and 10.93 days, respectively, in group A when compared to group B which was within 21.56 and 20.06 days, respectively.

Conclusion

We conclude that in our trial, prednisolone mouthwash with antioxidants was seen to be efficacious, safe, and reliable in the management of oral submucous fibrosis.

Collagen Membrane Over Buccal Fat Pad Versus Buccal Fat Pad in Management of Oral Submucous Fibrosis: A Comparative Prospective Study

OBJECTIVE

The objective of this study was to assess the effectiveness of collagen membrane as biological dressing over buccal fat pad (BFP) during crucial postoperative healing phase in the surgical management of oral submucous fibrosis (OSMF).

STUDY DESIGN

The study comprised of 40 patients of OSMF of group IVa (Khanna and Andrade). Patients were randomly divided in two groups (20 patients in each group). Group I patients were treated using buccal fat pad only, whereas collagen membrane was used as a covering over harvested BFP in group II patients. Postoperative follow-up was done at 1 week, 3 weeks, 6 months and 1 year.

RESULT

Mean postoperative mouth opening achieved in both the groups was comparable at every follow-up visit. Infection was evident in four patients of group I at 1-week follow-up, whereas none of the group II patients developed infection. Pain score was lesser in group II patients as compared to group I. Relapse was seen in two patients in group I and one patient in group II. Time taken for epithelialization was 2-3 weeks in both the groups.

CONCLUSION

Although intraoperative time was increased in group II application of collagen membrane reduced infection when compared with group I. Also, the chances of damage to BFP are reduced during the hygiene maintenance at surgical site and jaw-opening exercise. Reduction in pain scores during postoperative period in group II patients was an additional advantage.

Nasolabial and extended nasolabial flaps for reconstruction in oral submucous fibrosis

Objectives

The objective of the study was to evaluate the results of nasolabial/extended nasolabial flaps as a modality for treatment of oral submucous fibrosis.

Materials and Methods

Eleven patients of Stage III or IVa maximum interincisal opening were selected to be operated. Nasolabial/extended nasolabial flaps were done for both the sides. All of the flaps were done in a single stage and were inferiorly based. A similar flap harvest/surgical technique was utilized for all the cases.

Results

The preoperative mouth opening ranged from 5 to 16 mm, with a mean of 10.09 mm. At 6 months the mouth opening ranged from 29 to 39 mm. Some of the complications encountered were poor scar, wisdom tooth traumatising the flap, decreased mouth opening due to non compliance and too much bulk. All of theses were managed satisfactorily.

Conclusion

The nasolabial flap is a very reliable flap to restore the function of oral cavity. Important adjuvant measures are habit cessation, lifestyle changes, and aggressive physiotherapy.

Zinc, Copper, and Iron in Oral Submucous Fibrosis: A Meta-Analysis

Oral submucous fibrosis (OSF) is a potentially malignant disorder which causes fibrosis and inflammation of the oral mucosa. Studies have reported altered levels of trace elements in oral submucous fibrosis subjects, but findings have been inconsistent. The objective of this research is to perform a meta-analysis to summarize studies that report zinc (Zn), copper (Cu), and iron (Fe) in patients, with and without OSF. A literature search of Embase, PubMed, Cochrane Library, and Web of Science electronic databases was conducted for studies up to January 2017. A total of 34 reports met the inclusion criteria. The standardized mean difference was utilized as the effect size. The robust variance estimation method was chosen to handle dependency of multiple related outcomes in meta-analysis. There was a significant increase in the levels of Cu (effect size = 1.17, p value < 0.05, 95% confidence interval (CI): 0.164–2.171) and a significant decrease in levels of Zn (effect size = −1.95, p value < 0.05, 95% CI: −3.524 to −0.367) and Fe (effect size = −2.77, p value < 0.01, 95% CI: −4.126 to −1.406) in OSF patients. The estimation of Zn, Cu, and Fe levels may serve as additional biomarkers in the diagnosis and prognosis of OSF along with the clinical features.

A novel clinical protocol for therapeutic intervention in oral submucous fibrosis: An evidence based approach

Oral submucous fibrosis (OSMF) is a chronic, progressive, debilitating, scarring and crippling disorder of the oral cavity. It is a potentially malignant oral disease which predominantly affects people of South and Southeast Asia, especially Indian subcontinent, where chewing of areca nut and its commercial preparation is rampant. However, due to increase in immigration of people from the Indian subcontinent, the health professionals in many developed countries do come across this disease very often. Since decades, many treatment modalities are suggested and studied using medicines, surgery and physiotherapy, with varying degrees of benefit, but none have been able to cure this disease completely, and hence, it has become a challenging condition. The present article emphasizes on various therapeutic interventions used till date to curb the menace of this disease and the principal author with his vast academic research and clinical experience in treating this disease has proposed the stage-wise treatment regimen for OSMF. The current article is an attempt to compile the available treatment, its current status and future perspectives, so as to assist early intervention of the disease with evidence-based approach. This article will ignite the research minds of dental clinician, oral medicine specialist, otolaryngologist and general physician in treating OSMF.

Efficacy of oral colchicine with intralesional hyaluronidase or triamcinolone acetonide in the Grade II oral submucous fibrosis

Background and Objectives:

Oral submucous fibrosis (OSMF) is a potentially malignant disorder of oral mucosa affecting mainly population in South and Southeast Asia. The aim of this study is to compare the effectiveness of oral colchicine with intralesional injection of hyaluronidase or injection triamcinolone acetonide in patients with Grade II OSMF.

Materials and Methods:

The study included thirty patients of clinically diagnosed Grade II OSMF. Patients were divided randomly into two groups: Group A patients were treated by administrating tablet colchicine 0.5 mg twice daily with an intralesional injection of hyaluronidase 1500 IU with 0.5 ml of lignocaine hydrochloride at weekly interval for 12 weeks. Group B patients were treated by administering tablet colchicine 0.5 mg twice daily with an intralesional injection of triamcinolone acetonide 10 mg/ml at weekly interval for 12 weeks. Clinical diagnosis was based on burning sensation in mouth, blanching of mucosa, presence of vesicles or ulceration in oral cavity, and reduced mouth opening. Outcome assessment was done at intervals of 3 weeks, 6 weeks, 3 months, and 6 months.

Results:

Improvement in mouth opening and reduction in burning sensation was seen more in Group A patients. Improvement in blanching of mucosa was seen in both the groups.

Conclusion:

In conclusion, use of injection hyaluronidase with oral colchicine gave better results in terms of increase in mouth opening and improvement in burning sensation without notable side effects. However, for a definite conclusion, further study with large sample size and long follow-up is required.

Immediate versus delayed aggressive physical therapy following buccal fat pad interposition in oral submucous fibrosis-a prospective study in Central India

PURPOSE

Oral submucous fibrosis is a disease of an Indian subcontinent with obscure aetiology and poorly treated with varying signs and symptoms. OSMF occurs at any age but is most commonly seen in teenagers and adults in the age ranging between 16 and 35 years. A number of surgical treatments have been used for the treatment of oral submucous fibrosis with unpredictable results.

PATIENTS AND METHOD

In this study, 220 patients were randomly divided into two groups with mouth opening less than 16 mm and evaluated with immediate and delayed aggressive physiotherapy with buccal fat pad interposition after fibrotomy. Group A (n = 110) patients underwent aggressive mouth opening exercise from the next postoperative day while in group B (n = 110), patients underwent physiotherapy 7th day postoperatively. Pain and discomfort, mucosalization, infection, flap dehiscence and necrosis were noted. Patients were followed for 1 year on a regular interval basis.

RESULTS

At the end of 1-year follow up, the post-operative mean mouth opening in group A was 38.63 mm and 34.19 mm in group B. In group A, the immediate physiotherapy results in mild to moderate pain and discomfort to the patients as compared to no apparent pain in the group B. The mean mucosalization time in group A and group B was 4.2 and 5.1 weeks, respectively. Postoperatively, all patients achieve satisfactory mouth opening.

CONCLUSION

Immediate aggressive physiotherapy yields a comparatively superior result than delayed physiotherapy with respect to mouth opening in 1 year of follow-up.

Comparison of Extended Nasolabial Flap Versus Buccal Fat Pad Graft in the Surgical Management of Oral Submucous Fibrosis: A Prospective Pilot Study

AIM

To evaluate the application of extended nasolabial flap versus buccal fat pad graft in the surgical management of oral submucous fibrosis.

SETTINGS AND DESIGN

This prospective study was carried out in the Department of Oral and Maxillofacial Surgery, Tamil Nadu Government Dental College and Hospital, Chennai.

MATERIAL AND METHODS

A total of 8 patients (6 men and 2 women) with age range from 21 to 65 years were selected for study. These 8 patients were randomly divided into two groups of four namely group 1 and group 2. In group 1 patients, reconstruction was planned with extended nasolabial flaps and in group 2 patients, reconstruction was planned with buccal fat pad graft respectively.

STATISTICAL ANALYSIS USED

Paired t test, Independent sample t test, ANOVA test.

RESULTS

The mean preoperative mouth opening in group 1 was 8.5 mm and in group 2 was 11.75 mm. The mean increase in group 1 after one year of postoperative period was 21.50 mm and in group 2 was 24.75 mm.

CONCLUSIONS

In the present study, buccal fat pad graft proved to give better results as the interposition material as it has good patient acceptance, rapid epithelization, minimal donor site morbidity and minimal intra and postoperative complications.

Efficacy of buccal fat pad in the surgical management of oral submucous fibrosis: a prospective study

PURPOSE

Various surgical treatment modalities have been advocated in the surgical management of oral submucous fibrosis with variable results. This prospective study evaluates the efficacy of buccal fat pad in the surgical treatment of oral submucous fibrosis.

PATIENTS AND METHOD

In the present study, 20 patients were treated for oral submucous fibrosis with interincisal mouth opening less than 16 mm. Surgical procedure included fibrotomy, all third molar extractions, and coronoidotomy or coronoidectomy followed by reconstruction of fibrotomy defect with buccal pad of fat. Postoperatively, patients were prescribed nutritional and antioxidant supplements along with vigorous mouth opening exercise for 6 months. Regular follow-up was carried out for 2 years.

RESULTS

Excellent increase in the interincisal mouth opening was noticed relieving trismus. Patient's ability of masticate and tolerance to regular food was increased significantly. Buccal fat pad underwent rapid epithelization within a period of 5-7 weeks.

CONCLUSION

Buccal fat pad can be used effectively in the surgical management of oral submucous fibrosis with good functional and esthetic outcome, with only drawback of supple lobulated fat, which requires delicate handling and its limitation to reach anteriorly beyond the canine region.

Intralesional corticosteroids as a treatment for restricted mouth opening in oral submucous fibrosis

OBJECTIVES

Oral submucous fibrosis (OSF) is a chronic debilitating disease of the oral mucosa, associated with an increased risk of malignancy. The primary objective of this study was to evaluate the effectiveness of intralesional corticosteroid injection as a treatment modality for OSF. We also studied the correlation between the treatment outcome and a number of individual variables.

STUDY DESIGN

A total of 230 histologically confirmed patients with OSF were included in the study, of which 116 patients with a 30 mm or less interincisal mouth opening were subjected to intralesional injections of 40 mg methylprednisolone at monthly intervals for 6 consecutive months. The effect of the treatment was assessed by evaluating the degree of improvement in mouth opening.

RESULTS

All patients included in the study had a history of chewing areca nut. In paired comparison, statistically significant difference (t = -8.78; df = 115; P < .001) was observed in mouth opening over a period of 12 months in the patients who had corticosteroid injections.

CONCLUSIONS

Intralesional corticosteroid injection is one of the most widely implemented interventions for OSF at present, particularly for those patients with palpable fibrous bands. The present study provides justification for the use of corticosteroids in improving mouth opening.

Oral submucous fibrosis: a review of the current management and possible directions for novel therapies

This literature review addresses the attempted interventions for the management of oral submucous fibrosis. The literature supports the use of several medical interventions, including micronutrients, antioxidants, proteolytic enzymes, immune modulators (mainly steroids), and agents to promote blood flow. However, the numbers of reported randomized controlled trials are limited. Therefore, no recommendation can be made for any specific intervention. Until now, no single molecular pathway has been identified that is either necessary or sufficient for the development of fibrosis. This has been a bar for any molecular-targeted therapies. Because areca nut (an ingredient of betel quid) plays a major etiologic role in oral submucous fibrosis, cessation of areca nut use remains pivotal in the management of this disorder.

Platysma myocutaneous flap for reconstruction of intraoral defects following excision of oral sub mucous fibrosis: A report of 10 cases

Various surgical procedures are available for treating oral submucous fibrosis, but all of them have their inherent drawbacks. The superiorly based platysma myocutaneous flap is a common reconstruction option for intraoral defects followed after excision of fibrous bands in oral submucous fibrosis. The superiorly based flap has an excellent blood supply, but less efficient venous drainage when compared with posteriorly based flap. We present our results of using a superiorly based flap in the treatment of oral submucous fibrosis. Of 10 patients eight had no postoperative complications, one patient developed partial skin loss and other developed venous congestion which was managed conservatively.

Surgical Interventions in Oral Submucous Fibrosis: A Systematic Analysis of the Literature

BACKGROUND

Oral submucous fibrosis (OSMF) is a potentially malignant disorder of the oral cavity. The surgical management of this condition involves excision of the fibrotic bands and interpositional grafts to retain the increased oral opening. Various procedures and graft material have been utilised with differing success rates.

OBJECTIVES

The present review aims to collate and analyze from world literature the different modalities utilized in the surgical management of OSMF. The reasons for the choice of a particular surgical procedure, the study protocol, the average follow-up period and the results were scrutinized.

MATERIALS AND METHODS

The PRISMA protocol was followed for the systematic review. Search engines and medical databases like Ovid, Medline, Pubgate, Researchgate, PubMed, Google etc. were tapped for information related to the subject. The search words "OSMF", "surgical interventions in OSMF", "flaps and grafts in treatment of OSMF" were employed for retrieval of data. An analysis of the treatment modalities, the reason for the selection of a particular modality, the organization of the sample selection and the follow-up periods including the proclaimed success rates was done.

RESULTS

The review resulted in a total of 56 articles on the subject from the sources mentioned above. A total of 995 surgically treated cases were included in the analysis. Interestingly the review revealed very few controlled clinical trials, most being random trials on surgical procedures in small groups of patients with very short follow up periods. The choice of procedure seems to be determined entirely by the preference of the operator/s.

CONCLUSIONS

There exist no definite protocols for the adoption of a particular treatment mode in OSMF. Adequate documentation and follow up need to be established to statistically analyse the results and proclaimed successes of various treatment modalities.

Efficacy of nasolabial flap in reconstruction of fibrotomy defect in surgical management of oral submucous fibrosis: a prospective study

PURPOSE

Various surgical modalities have been used in the surgical management of oral submucous fibrosis with variable results. This prospective study evaluates the efficacy of nasolabial flap in the reconstruction of fibrotomy defect in surgical treatment of oral submucous fibrosis in terms of functional and esthetic outcomes.

MATERIAL AND METHOD

In this prospective study, we treated 20 patients of oral submucous fibrosis surgically. The surgical protocol was consisting of bilateral fibrotomy, temporal myotomy, and coronoidotomy or coronoidectomy followed by reconstruction of fibrotomy defect with bilateral extended nasolabial flaps. All patients were prescribed with nutritional supplements and antioxidants. Vigorous mouth opening exercise was made compulsory for every patient. Preoperative and postoperative evaluation was done for interincisal mouth opening, function of mastication, and cosmetic results. Patient's regular follow-up was done for 2 years.

RESULTS

Postoperatively, we noted excellent increase in the interincisal mouth opening relieving trismus. Patient's ability to chew solid food was increased significantly. Extraoral scar was minimal and well accepted by all the patients. There was no morbidity of the donor site. There was no injury to the facial nerve in all cases. The only drawback was intraoral hair growth which went on reducing with mucosalization of the graft tissue.

CONCLUSION

Random pattern nasolabial flap is a very good option for intraoral reconstruction of fibrotomy defect in surgical treatment of oral submucous fibrosis with excellent functional and cosmetic results with minimal complications.

A Sectional Splint for Maintaining Surgically Enhanced Vertical Height in an Oral Submucous Fibrosis Patient: A Case Report

Oral submucous fibrosis (OSMF) is a chronic inflammatory disease that results in a progressive juxtaepithelial fibrosis of the oral soft tissues, causing an increasing difficulty in mouth opening, chewing, swallowing and speaking. It is regarded as a precancerous and potentially malignant condition. The fibrosis of oral mucosa leads to limited mouth opening and difficulty in mastication. Prosthetic rehabilitation of patients with OSMF offers a formidable challenge due to the restricted mouth opening. Management of the limited mouth opening is usually by surgery. Herein, we describe a procedure to maintain the increased mouth opening that is achieved through surgery. Maintaining this opening would make it easier for any further prosthetic rehabilitation at a later stage.

A randomized double-blind, multiple-arm trial comparing the efficacy of submucosal injections of hyaluronidase, dexamethasone, and combination of dexamethasone and hyaluronidase in the management of oral submucous fibrosis

OBJECTIVE

Numerous treatment modalities for oral submucous fibrosis (OSF) have been advocated over the years. However, its medical treatment is not yet fully standardized. This randomized double-blind trial assessed and compared the effects of two commonly used drugs, independently and in combination.

METHODS

Forty-five patients were staged clinically and histopathologically for OSF and were randomly divided into three groups of 15 each by permuted block randomization. Each group received biweekly submucosal injections of hyaluronidase (1500 IU), dexamethasone (8 mg) or a combination of both (750 IU and 4 mg), respectively, for a period of 5 weeks. Improvement in pain upon opening, burning sensation, and tightness of mucosa as perceived by the patient, as well as improvement in mouth opening measured clinically were determined at the end of week 2, months 1, 2, 3, and 6 after the final injection. Results were compared and statistically analyzed using analysis of variance.

RESULTS

Submucosal injection of hyaluronidase gave a quicker and better improvement of measured symptoms.

CONCLUSIONS

Biweekly submucosal injection of hyaluronidase over a period of 5 weeks appears to be a viable treatment option for OSF.

Clinical evaluation of the role of tulsi and turmeric in the management of oral submucous fibrosis: A pilot, prospective observational study

The aim of the present study was to investigate the clinical efficacy of herbal medicines (1 gm tulsi and 1 gm turmeric mixed in glycerine base) for the treatment of oral submucous fibrosis (OSMF). Forty-one patients in the age group of 17- 56 years without any systemic complications were included in the study. The patients were treated with medicines, which were to be applied 3-4 times a day. Blood samples were collected before and after treatment to screen for any systemic changes due to these medications. Burning sensation and mouth opening were recorded before and after treatment. Patients were followed up on monthly subsequent visits for three months. Changes in the burning sensation on visual analogue scale (VAS) scale and difference in the mouth opening were analyzed statistically. A statistically significant improvement was seen in both burning sensation and mouth opening. Tulsi and turmeric offers a safe and efficacious combination of natural products available for symptomatic treatment of OSMF.

Oral submucous fibrosis: an update

Oral submucous fibrosis (OSF) is a premalignant condition caused by betel chewing. It is very common in Southeast Asia but has started to spread to Europe and North America. OSF can lead to squamous cell carcinoma, a risk that is further increased by concomitant tobacco consumption. OSF is a diagnosis based on clinical symptoms and confirmation by histopathology. Hypovascularity leading to blanching of the oral mucosa, staining of teeth and gingiva, and trismus are major symptoms. Major constituents of betel quid are arecoline from betel nuts and copper, which are responsible for fibroblast dysfunction and fibrosis. A variety of extracellular and intracellular signaling pathways might be involved. Treatment of OSF is difficult, as not many large, randomized controlled trials have been conducted. The principal actions of drug therapy include antifibrotic, anti-inflammatory, and antioxygen radical mechanisms. Potential new drugs are on the horizon. Surgery may be necessary in advanced cases of trismus. Prevention is most important, as no healing can be achieved with available treatments.

Evaluation of medicinal interventions for the management of oral submucous fibrosis: a systematic review of the literature

Oral submucous fibrosis is a chronic, progressive scarring disease associated with both significant morbidity including pain and limited mouth opening and an increased risk for malignancy. This systematic review evaluated the different medicinal (i.e. nonsurgical) interventions available for the management of oral submucous fibrosis. An automated literature searches of online databases from January 1960 to December 2013 were performed and only studies with high level of evidence based on the guidelines of the Oxford Centre for evidence-based medicine were selected. Thirteen studies (3 randomized controlled trials and 10 clinical trials/controlled clinical trials) were included and drugs like steroids, hyaluronidase, human placenta extracts, chymotrypsin and collagenase, pentoxifylline, nylidrin hydrochloride, iron and multivitamin supplements including lycopene were used. There is a clear lack of evidence on the available drug treatment for oral submucous fibrosis and further high quality randomized controlled trials are needed to evaluate the different therapeutic agents.

Comparative study of the efficacy of herbal antioxdants oxitard and aloe vera in the treatment of oral submucous fibrosis

Objectives: Oral submucous fibrosis (OSMF) is a potentially malignant disorder predominantly seen in the Indian subcontinent due to areca nut, tobacco and their products. The aim of the present study was to compare the efficacy of oxitard and aloe vera in the management of OSMF. Material and Methods: 120 subjects with OSMF were included in the study. The patients were clinico-pathologically diagnosed and divided equally in 2 groups, Group A (oxitard group) and Group B (aloe vera group). Group A was administered 2 oxitard capsules twice daily and Group B was given 5 mg aloe vera gel to be applied topically thrice daily for 3 months. Different clinical parameters were evaluated at regular intervals. Data was analyzed using the Student’s paired t test and Chi-square test. P-value <0.001 was considered to be statistically significant. Results: Clinical improvements in mouth opening and tongue protrusion was significant in the oxitard group (p=0.0005). Subjective symptoms of pain associated with the lesion (p=0.0003), difficulty in swallowing (p=0.0000) and speech (p=0.0001) also significantly improved in the Group A. The improvement in burning sensation was not statistically significant between the 2 groups (p=0.002). There was a mild to moderate decrease in the size of the lesion. Conclusions: Though there is no definitive treatment for the condition however, overall assessment of symptoms like mouth opening, tongue protrusion, difficulty in swallowing and speech and pain associated with the lesion showed that oxitard capsules can bring about significant clinical improvements than aloe vera gel in the treatment of OSMF.

Key words:Oral submucous fibrosis, oxitard capsules, aloe vera, burning sensation, mouth opening.

Management for premalignant lesions of the oral cavity

Premalignant lesions of the oral cavity present as visibly abnormal areas of mucosa and may be a source of significant anxiety for the patient and the clinician. Suspicious lesions should be biopsied to evaluate for dysplasia. The risk of malignant transformation may relate to patient characteristics, environmental risk factors and genetic alterations. Management of such lesions hinges on risk modification, surveillance, symptom management and directed biopsies. Excision or ablation of dysplastic lesions is indicated. We review the current evidence relating to management of premalignant lesions of the oral mucosa and make recommendations for practice patterns.

Spirulina and pentoxyfilline - a novel approach for treatment of oral submucous fibrosis

BACKGROUND

Oral submucous fibrosis is a habit associated insidious precancerous condition of the oral cavity commonly found in Asian countries. Many treatment modalities have been attempted in treating the condition apart from steroids which have been the main stay. Hence the present study was designed to assess the efficacy of spirulina and pentoxyfilline and also to compare them in oral submucous fibrosis.

MATERIAL AND METHODS

Fourty Patients with clinico-histological diagnosis of oral sub mucous fibrosis were selected and divided into two groups with 20 in each group by simple randomization method. Group I received Pentoxyfilline and Group II Spirulina for period of 3 months. The efficacy was assessed by parameters like mouth opening, burning sensation and tongue protrusion using vernier caliper, visual analog scale and a metric scale respectively along with the side effects.

RESULTS

Student's t-test was applied to obtain the results. Both Pentoxyfilline and Spirulina groups showed statistically significant results (p=0.000) in all the three parameters namely mouth opening, burning sensation and tongue protrusion. On comparing both the drugs statistically insignificant results were obtained for mouth opening (p=0.35) and tongue protrusion (p=0.25) but statistically significant difference was seen in subjective parameter i.e burning sensation (p=0.04). Side effects like bloating of stomach, nausea and gastritis were noted in the pentoxyfilline group in contrast to Spirulina group.

CONCLUSION

Newer drugs Pentoxyfilline and Spirulina showed promising results in treatment of Oral sub mucous fibrosis. Spirulina was used for the first time for treatment of Oral submucous fibrosis (OSMF) and it proved to be superior than pentoxyfilline as no side effects were observed. Also it was superior in reducing burning sensation and hence can be advised in OSMF patients suffering from severe subjective symptoms.

Is buccal fat pad a better option than nasolabial flap for reconstruction of intraoral defects after surgical release of fibrous bands in patients with oral submucous fibrosis? A pilot study: a protocol for the management of oral submucous fibrosis

PURPOSE

The aim this study was to compare the buccal fat pad (BFP) and nasolabial flap for reconstruction of intraoral defects after release of fibrous bands in patients with oral submucous fibrosis (OSF).

MATERIALS AND METHODS

This is a comparative study. The study sample was derived from the population of patients who presented, with restricted mouth opening of less than 20 mm, to the Department of Oral and Maxillofacial Surgery, Swargiya Dada Saheb Kalmegh Dental College and Hospital Hingna Nagpur. The patients were divided into two groups. In Group I (n = 10) reconstruction was performed with a nasolabial flap and in Group II (n = 10) with BFP. Both groups were analysed separately for mouth opening (interincisal distance in millimetres) preoperatively and 20 months postoperatively, time taken for epithelialization of BFP and nasolabial flaps. Statistical analysis was performed with SPSS statistical software for Windows, version 8.0 (SPSS, Inc, Chicago, IL) using the _2 test and Student's t test.

RESULTS

In all 20 patients the interincisal mouth opening was (mean) 11 mm (3-19 mm) preoperatively which improved to a mean of 42 mm (23-52 mm). In Group I there were more complications as compared to Group II such as partial flap necrosis particularly at the tips, temporary widening of oral commissure and subluxation of TMJ. The unsightly extraoral scar and intraoral growth of hairs were not seen in Group II.

CONCLUSION

BFP is the better choice for reconstruction in comparison to nasolabial flap.

Pathogenesis and therapeutic intervention of oral submucous fibrosis

Oral submucous fibrosis (OSF) is a chronic, progressive, potentially malignant condition affecting the oral cavity and frequently involving the upper part of the aerodigestive tract including the oropharynx and the upper part of the esophagus. It is characterized by juxtaepithelial inflammatory reaction and progressive fibrosis of lamina propria, leading to stiffening of the oral mucosa eventually causing trismus. This condition is associated with significant morbidity and high risk of malignancy. Over the years, several drugs and combinations have been tried for the treatment of submucous fibrosis, but with limited success, because of its unclear molecular pathogenesis. Till date, there are no known effective treatments for OSF. The aim of this article is to emphasize on the molecular changes taking place in OSF and possible therapeutic interventions.

Excision of oral submucous fibrosis and reconstruction with full thickness skin graft: a case study and review of the literature

Oral submucous fibrosis is a chronic debilitating disease characterized by gradually increasing fibrosis of the oral cavity and pharynx, mainly the buccal mucosa, resulting in trismus. The highest incidence of oral submucous fibrosis is seen in South India due to various deleterious habits. In spite of the numerous medical modalities employed in the management of oral submucous fibrosis, occasionally surgical intervention becomes inevitable. Various surgical approaches have been used to reconstruct the surgical defects following excision of fibrous bands. Full thickness skin grafts have been described in the literature with variable outcomes. In the present study a 38-year-old male presented with severe oral submucous fibrosis of the buccal mucosa, which was successfully treated and reconstructed using full thickness skin graft with stable functional result after one year of treatment. An integrated review of the literature regarding etiology, histopathology, diagnostic, and treatment modalities of the disease follows.