Evaluation of oral submucous fibrosis using ultrasonographic technique: A new diagnostic tool

Comparative Study of Injection Triamcinolone and Hyaluronidase Combination with Injection Platelet Rich Plasma (PRP) in Management of Oral Submucous Fibrosis (OSMF)

This study aimed to compare the results of injection triamcinolone and hyaluronidase combination with injection Platelet Rich Plasma (PRP) in management of Oral Submucous Fibrosis (OSMF). Present study was carried out in randomly divided two groups of 30 patients each of OSMF who all are presented with chief complain of reduced mouth opening. Group A patients were given 1 ml of injection triamcinolone and hyaluronidase combination. Group B patients received 1 ml of injection Platelet Rich Plasma. Both injections were given intralesionally once a week for 6 weeks. Results of ANOVA shows significant better results in improving mouth opening in group B patients receiving injection Platelet Rich Plasma as a treatment. In Group A, patients shows improvement in Maximum interincisal distance (MIID) of mean 6.51 ± 1.02 mm as compared to the patients in group B shows improvement in MIID of mean 9.53 ± 1.06 mm (p value < 0.05). Treatment of OSMF with injection Platelet Rich Plasma is a novel method and found to be more efficient than treatment with injection triamcinolone and hyaluronidase combination.

Overview of Ultrasound in Dentistry for Advancing Research Methodology and Patient Care Quality with Emphasis on Periodontal/Peri-implant Applications

BACKGROUND

Ultrasound is a non-invasive, cross-sectional imaging technique emerging in dentistry. It is an adjunct tool for diagnosing pathologies in the oral cavity that overcomes some limitations of current methodologies, including direct clinical examination, 2D radiographs, and cone beam computerized tomography. Increasing demand for soft tissue imaging has led to continuous improvements on transducer miniaturization and spatial resolution. The aims of this study are (1) to create a comprehensive overview of the current literature of ultrasonic imaging relating to dentistry, and (2) to provide a view onto investigations with immediate, intermediate, and long-term impact in periodontology and implantology.

METHODS

A rapid literature review was performed using two broad searches conducted in the PubMed database, yielding 576 and 757 citations, respectively. A rating was established within a citation software (EndNote) using a 5-star classification. The broad search with 757 citations allowed for high sensitivity whereas the subsequent rating added specificity.

RESULTS

A critical review of the clinical applications of ultrasound in dentistry was provided with a focus on applications in periodontology and implantology. The role of ultrasound as a developing dental diagnostic tool was reviewed. Specific uses such as soft and hard tissue imaging, longitudinal monitoring, as well as anatomic and physiological evaluation were discussed.

CONCLUSIONS

Future efforts should be directed towards the transition of ultrasonography from a research tool to a clinical tool. Moreover, a dedicated effort is needed to introduce ultrasonic imaging to dental education and the dental community to ultimately improve the quality of patient care.

Oxidative-protective effect of nuclear receptor coactivator 7 on arecoline-induced endothelial-to-mesenchymal transition

OBJECTIVE

Overproduction of reactive oxygen species (ROS) has been implicated in inflammatory activities and tumorigenesis in oral submucous fibrosis (OSF). Nuclear receptor coactivator 7 (NCOA7) is capable of regulating cellular responses to ROS. The aim of this study was to investigate the expression of NCOA7 in endothelial cells and the role of NCOA7 in areca nut-induced endothelial-to-mesenchymal transition (EndMT).

STUDY DESIGN

Immunohistochemistry and immunofluorescence were used to detect the expression of NCOA7 in endothelia. Human umbilical vein endothelial cells (HUVECs) were treated with various dosages of arecoline (0, 5, 10, 20 μg/mL); then NCOA7 expression, the correlation of NCOA7 with EndMT, and the potential signaling were analyzed by using small interfering RNA (siRNA) transfection, reverse transcription polymerase chain reaction, Western blotting, and flow cytometry.

RESULTS

NCOA7 was significantly elevated in OSF tissues, as detected with immunohistochemistry and immunofluorescence. After arecoline treatment, NCOA7 expression and EndMT were induced in HUVECs. Transfection of HUVECs with si-NCOA7, which reduced 73% of NCOA7 expression, aggravated the arecoline-induced EndMT process. Inhibition of ROS markedly, but not completely, reverses this arecoline-induced EndMT in si-NCOA7 cells.

CONCLUSIONS

This study highlights NCOA7 as a potential target for therapeutic intervention to mediate EndMT via ROS species production.

YAP-Induced Endothelial-Mesenchymal Transition in Oral Submucous Fibrosis

Oral submucous fibrosis (OSF) is a potentially malignant disorder. Current studies have shown that chewing areca nut is considered the main cause of OSF, and endothelial-mesenchymal transformation (EndMT) participates in the occurrence and development of the fibrotic lesion. However, the specific molecular mechanisms and treatments remain unclear. Here, we report the mechanism of arecoline-induced EndMT and the importance of this mechanism in OSF, and we also identify potential therapeutics for decreasing OSF incidence. We demonstrate the overexpression of Yes-associated protein (YAP) in human samples and that it was significantly associated with OSF pathologic stage. Arecoline activated YAP by increasing reactive oxygen species levels and inducing the PERK pathway (eukaryotic translation initiation factor 2 alpha kinase 3), resulting in the initiation of EndMT and leading to OSF. Verteporfin, a YAP–TEA domain pathway inhibitor, suppressed EndMT and decreased collagen accumulation, resulting in the alleviation of OSF in mice. These data indicate that arecoline regulates the activity of YAP and highlight an alternative method for treating OSF.

Ultrasonographic evaluation of submucosal thickness in oral submucous fibrosis patients: a cross-sectional study

Purpose

To evaluate the role of ultrasonography in oral submucous fibrosis (OSMF) patients.

Material and methods

A total of 150 subjects were divided equally into six groups (Group I: 25 healthy subjects; Group II: 25 healthy subjects with habit; Group III: 25 OSMF stage I; Group IV: 25 OSMF stage II; Group V: 25 OSMF stage III; and Group VI: 25 stage OSMF IVA). The grading of OSMF were done according the clinical classification given by Khanna and Andrade (2005). After fulfilling inclusion and exclusion criteria each subject underwent extraoral ultrasonographic evaluation of submucosal thickness and vascularity in terms of peak systolic velocity (PSV), bilaterally on buccal and labial mucosa. Furthermore, statistical comparison of each group was done, and sensitivity and specificity of USG measurements was obtained in comparison with clinical diagnosis. The statistical analysis was performed using SPSS ver. 20.0.

Results

A statistically significant increase in mean submucosal thickness was shown, and a decrease in PSV with the advancement of severity of the OSMF. In ultrasonographic diagnosis of OSMF, the reported submucosal thickness had a sensitivity, specificity, PPV, NPV, and accuracy was 80%, 100%, 100%, 71.4%, and 87%, respectively, but PSV failed to classify the lesion.

Conclusions

Because the severity of the disease showed a direct relationship with submucosal thickness and an inverse relationship with PSV, habit-induced mucosal alteration in submucosal thickness can be seen on USG, which cannot be appreciated on clinical examination. Hence, USG can be a promising tool for early diagnosis, assessment of the severity, and evaluation of prognosis of OSMF.

Evaluation of Oral Pentoxifylline in the Management of Oral Submucous Fibrosis - An Ultrasonographic Study

AIM AND OBJECTIVE

To evaluate the therapeutic efficacy of oral pentoxifylline in the treatment of oral submucous fibrosis (OSMF) patients by assessing the clinical symptoms such as burning sensation, mouth opening, and submucosal layer thickness and echogenicity using ultrasonography, both pre- and post-operatively.

MATERIALS AND METHODS

Thirty study subjects were included in the study and divided into two groups in single-blind randomized manner, oral pentoxifylline and dexamethasone group. Burning sensation, mouth opening, ultrasonographic submucosal thickness, and echogenicity were recorded both pre- and post-operatively. Any adverse effects reported by the patients were also noted. The data collected were statistically analyzed, and response to pentoxifylline and intralesional dexamethasone with hyaluronidase was observed using ultrasonography.

RESULTS

A highly significant reduction (P < 0.001) in burning sensation, improvement in mouth opening, and changes in submucosal thickness were noticed in both groups, and significant improvement (P < 0.05) in echogenicity in both the groups was noticed. However, pentoxifylline group showed marginally better improvement than dexamethasone group.

CONCLUSION

Pentoxifylline can bring about significant improvement in OSMF, which can be used as better alternative where intralesional steroid was contraindicated or not well tolerated.

Limited mouth opening in oral submucous fibrosis: reasons, ramifications, and remedies

Limited mouth opening (LMO) in oral submucous fibrosis (OSF) has been attributed to both the submucosal and muscle fibrosis (MF). While reflectory trismus was proposed before as an auxiliary mechanism by another group, the stretch-mediated muscle damage (MSD), histopathological changes in blood vessels (such as endothelial dysfunction, endothelial hypertrophy, and endarteritis obliterans), and upregulated anaerobic isoforms of lactate dehydrogenase (LDH) have been proposed by us as complementary events leading to MF. Additionally, the amount of hypoxia-mediated upregulation of anaerobic isoforms of LDH determines the extent of MF. Radiotherapy (RT)-mediated release of reactive oxygen species causes vascular damage thereby worsening hypoxia. While the alteration in LDH levels secondary to hypoxia enhances fibrosis, RT worsens it. Oral squamous cell carcinoma occurring in the background of OSF is an absolute contraindication for RT as it augurs unfavorable prognosis. An algorithm to demonstrate this with evidence is clearly depicted. The role of HIF-1α in the progression of OSF and its malignant transformation, and the consideration of hyperbaric oxygen therapy as a therapeutic remedy in OSF are underscored.

Arecoline increases basic fibroblast growth factor but reduces expression of IL-1, IL-6, G-CSF and GM-CSF in human umbilical vein endothelium

BACKGROUND

Areca nut chewing is associated with oral submucous fibrosis (OSF). Raised vascular basic fibroblast growth factor may induce fibrosis. Arecoline is a muscarinic alkaloid in areca nut, which we earlier reported causes injury and necrosis of human endothelium.

MATERIALS AND METHODS

Human umbilical vein endothelial cells were exposed to arecoline with or without tumor necrosis factor-α, and separately to acetylcholine, muscarine, or nicotine. Protein levels of basic fibroblast growth factor, as well as the inflammatory cytokines: granulocyte colony stimulating factor (G-CSF), granulocyte-macrophage colony stimulating factor, and Interleukins-6, 1-α and 1-β, were determined by enzyme-linked immunosorbent assay. mRNA levels were established by real-time reverse transcription polymerase chain reaction.

RESULTS

Basic fibroblast growth factor was released into the culture medium at arecoline levels causing necrosis (P < 0.05). This contrasted with an opposite effect of arecoline on levels of the inflammatory cytokines (P < 0.05). Tumor necrosis factor-α increased IL-6 and granulocyte-macrophage colony stimulated factor, but arecoline reduced this stimulated expression (P < 0.05). Arecoline had no effect on mRNA for basic fibroblast growth factor, although there was reduced mRNA for the separate inflammatory cytokines studied. The effect of acetylcholine, muscarine, and nicotine was minimal and dissimilar to that of arecoline.

CONCLUSIONS

Data raise the possibility that arecoline-induced, vascular basic fibroblast growth factor contributes to OSF, by combining increased growth factor expression with endothelial necrosis, and thus driving fibroblast proliferation.

Arecoline is cytotoxic for human endothelial cells

BACKGROUND

Oral submucous fibrosis is a pre-malignant fibrotic condition caused by areca nut use and involves reduced mucosal vascularity. Arecoline is the principal areca nut alkaloid and is cytotoxic for epithelium and fibroblasts. Endothelial cell cycle arrest is reported on exposure to arecoline, as is cytotoxicity for endothelial-lung carcinoma hybrid cells. We here describe cytotoxicity for primary human endothelial cultures from seven separate donors.

MATERIALS AND METHODS

Human umbilical vein endothelial cells were exposed to increasing concentrations of arecoline and examined by: phase-contrast microscopy, haemocytometer counts, transmission electron microscopy, lactate dehydrogenase release and the methyl-thiazol-tetrazolium assay.

RESULTS

Vacuolation and detachment of endothelium were observed at and above arecoline concentrations of 333 μg/ml or more. Ultrastructural features of cellular stress were seen after 24-h treatment with 111 μg/ml arecoline and included reduced ribosomal studding of endoplasmic reticulum, increased autophagolysosomal structures, increased vacuolation and reduced mitochondrial cristae with slight swelling. Similar changes were seen at 4 h with arecoline at 333 μg/ml or above, but with more severe mitochondrial changes including increased electron density of mitochondrial matrix and greater cristal swelling, while by 24 h, these cells were frankly necrotic. Haemocytometer counts were paralleled by both lactate dehydrogenase release and the methyl-thiazol-tetrazolium assays.

CONCLUSIONS

Arecoline is cytotoxic via necrosis for endothelium, while biochemical assays indicate no appreciable cellular leakage before death and detachment, as well as no clear effect on mitochondrial function in viable cells. Arecoline toxicity may thus contribute to reduced vascularity in oral submucous fibrosis.

Ultrasonographic evaluation of oral submucous fibrosis and masseteric hypertrophy

Objectives:

To evaluate the efficacy of ultrasonography (USG) as a non-invasive tool in assessing the severity of oral submucous fibrosis (OSMF) and also to assess the relationship between OSMF and hypertrophy of the masseter muscle.

Materials and Methods:

The submucosal thickness in buccal mucosa and masseteric muscle hypertrophy were measured using ultrasound (10-15 MHz) in 60 patients comprising 30 OSMF patients and 30 controls.

Results:

Results were analyzed by one way analysis of variance, Chi-square test and t-test. As the stages of OSMF advanced there was an increase in submucosal thickness of the buccal mucosa as well as masseter muscle thickness in both relaxed and contracted state in the study group when compared with controls (P < 0.005).

Conclusion:

USG is an effective non-invasive zero radiation tool for assessing the progression of OSMF.

Ultrasonographic evaluation of oral submucous fibrosis in habitual areca nut chewers

OBJECTIVES

To characterize the sonographic features of the buccal mucosa in patients with oral submucous fibrosis (OSF).

METHODS

Three groups (controls with areca-related habits, controls without areca-related habits and clinically diagnosed OSF cases), each comprising 30 subjects, were included in the study. After a thorough clinical examination, transcutaneous B-mode ultrasonography was performed with a multifrequency linear transducer (5-10 MHz) for anterior and posterior buccal mucosa bilaterally. Both clinical and ultrasound findings were recorded by three independent observers. One-way analysis of variance and Tukey's honestly significant difference post-hoc tests were used for statistical comparisons between groups and Pearson χ(2) tests to compare the proportions. Kappa statistics was used to determine the interobserver agreement.

RESULTS

The submucosa that appeared hypoechoic in the control groups had significantly increased echogenicity in the case group (hypo- to isoechoic in 46.7% and isoechoic in 53.3%). The differentiation between the submucosa and the muscle layer appeared distinct in the control groups while it was not clear in the case group (indistinct in 50% and completely lost in 50%). The number of sites found positive on the ultrasound was significantly greater than the number of clinically positive sites. There was a very good interobserver consistency in clinical and ultrasound findings.

CONCLUSIONS

Ultrasonography of the buccal mucosa demonstrates increased submucosal echogenicity and reduced echo differentiation between submucosa and muscle layer in OSF cases. Hence, it can be used as a non-invasive imaging modality to assess the disease extent and severity across the entire buccal mucosa to supplement clinical evaluation.