Proliferative verrucous leukoplakia/multifocal leukoplakia in patients with and without oral submucous fibrosis

BACKGROUND

Oral submucous fibrosis (OSF) and proliferative verrucous leukoplakia (PVL) are established as oral potentially malignant disorders. Dual pathology of the two conditions is not commonly encountered in clinical practice. This study aims to present a case series of multifocal leukoplakia in patients with and without OSF to outline the clinical behavior and challenges in the management of this high-risk group in clinical practice.

MATERIAL AND METHODS

We retrospectively analyzed cases of six Indian patients (four with OSF) managed over a period of 5.5 to 13 years at the Government Dental College, Nagpur. Patient data consisting of age, gender, medical history, habits, clinical findings, and biopsy reports were recorded at the initial visit. During follow-up visits, the clinicopathological data were reassessed. When surgical intervention failed to arrest the disease or when surgery was contraindicated metronomic therapy with Folitrax 15 mg once a week and Celecoxib 100mg twice daily was initiated.

RESULTS

All patients developed PVL after the initial pathology diagnosis of OSF or oral leukoplakia. Initial lesions were either homogenous or non-homogenous leukoplakia. All patients developed multiple recurrences, regional or systemic metastasis. Despite thorough interventions, the patients died of, or with the disease.

CONCLUSIONS

The occurrence of two or more oral potentially malignant disorders poses challenges in patient management and possibly presents a higher risk of malignant transformation. More clinical trials are necessary to assess the benefits of metronomic therapy for patients diagnosed with aggressive PVL concurrently found with OSF.

Etiology of Oral Potentially Malignant Disorders and Squamous Cell Carcinoma Based on Cellular Stress Regulation and Matrix Stiffness

The oral cavity serves as the initial segment of the digestive system and is responsible for both nutritional supplementation and the mechanical breakdown of food. It comprises distinct hard and soft tissues; the oral mucosa is subject to mechanical stress and interaction with microbiota. In oral cancer, tumors exhibit abnormal cellular networks and aberrant cell-cell interactions arising from complex interplays between environmental and genetic factors. This presents a challenge for clinicians and researchers, impeding the understanding of mechanisms driving oral cancer development and treatment strategies. Lesions with dysplastic features are categorized under oral potentially malignant disorders, including oral leukoplakia, erythroplakia, oral submucous fibrosis, and proliferative verrucous leukoplakia, carrying a high malignancy risk. In this review, we discuss oral cancer cell characteristics and the stiffness of the surrounding matrix. We also discuss the significance of stiffness equilibrium in oral potentially malignant disorders, particularly oral submucous fibrosis, possibly triggered by mechanical stress such as betel quid chewing.

Oral submucous fibrosis stimulates invasion and epithelial-mesenchymal transition in oral squamous cell carcinoma by activating MMP-2 and IGF-IR

Oral submucous fibrosis (OSF) involves a high risk of malignant transformation and has been implicated in oral cancer. Limited studies have been conducted on the role of OSF in relation to the invasive capabilities and epithelial-mesenchymal transition (EMT) in oral cancer. Herein, we investigated the effects of OSF on the microenvironment of human oral cancer cells. The results showed that the conditioned medium (CM) of fibrotic buccal mucosal fibroblasts (fBMFs) strongly induced the invasion of oral cancer cells and increased the activities of matrix metalloproteinase-2. OSF significantly induced the EMT in oral cancer cells and downregulated epithelial markers, such as E-cadherin, but significantly elevated vimentin, fibronectin, N-cadherin, RhoA, Rac-1 and FAK. Insulin-like growth factor-1 (IGF-1) was elevated in OSF. The protein levels of the IGF-1R were upregulated specifically in fBMF CM treatment for oral cancer cells, and the IGFR gene was confirmed by The Cancer Genome Atlas patient transcriptome data. The Kaplan-Meier curve analysis revealed that patients with oral squamous cell carcinoma and high IGFR expression levels had poorer 5-year survival than those with low IGFR expression (p = 0.004). The fBMF-stimulated EMT cell model may recapture some of the molecular changes during EMT progression in clinical patients with oral cancer.

Differential expression of programmed death-1 and its ligand, programmed death ligand-1 in oral squamous cell carcinoma with and without oral submucous fibrosis

OBJECTIVE

The aim of our study was to investigate the expression of programmed death ligand-1 (PD-L1)/programmed death-1 (PD-1) between oral squamous cell carcinoma (OSCC) patients with and without oral submucous fibrosis (OSF), and its correlation with clinic-pathologic features and its prognostic value.

METHODS

PD-L1 and PD-1 expression was evaluated by immunohistochemical staining, double immunofluorescent staining and real-time PCR, and the correlation of PD-L1/PD-1 expression with clinical outcome was assessed.

RESULTS

The level of PD-L1 expression was significantly higher in OSCC with OSF than in OSCC without OSF (p = 0.006). Moreover, PD-L1 expression was strongly correlated with lymph node metastasis (p = 0.016), and advanced tumor stage (p = 0.030). Increased PD-L1 expression was positively correlated with the incidence of OSCC with OSF (p = 0.006, p = 0.008, respectively). PD-L1 expression was an independent marker of unfavorable prognosis (p = 0.035, p = 0.048, respectively). High PD-L1 expression had a significantly worse outcome in OSCC patients with OSF (p = 0.014). Double immunofluorescent staining showed that OSCC with OSF were more strongly expressed both PD-L1 and PD-1 than OSCC without OSF. Moreover, the expression of PD-L1 were upregulated in OSCC tissues than normal control (p = 0.0422), and both PD-L1 and PD-1 was significantly higher in OSCC with OSF than OSCC without OSF tissues (p = 0.0043 and, p = 0.0012, respectively).

CONCLUSIONS

The present study suggested that PD-L1 may be an unfavorable indicator for prognosis. PD-L1/PD-1 signaling might play an important role in the malignant transformation of OSF, and targeting PD-L1/PD-1 signaling may be a new therapeutic strategy for OSCC, especially in OSCC patients with OSF.

[Periodontal status in patients with oral submucous fibrosis]

OBJECTIVE

To investigate the periodontal status in patients with oral submucous fibrosis (OSF), and to provide reference for the treatment and prophylaxis in patients with OSF and betel chewers.

METHODS

Fifty samples clinically and pathologically diagnosed as OSF patients were selected as the OSF group, another 50 age-matched healthy volunteers in the similar living condition were compared with the OSF patients and non-betel nut chewers were classified as the control group. The 5 periodontal clinical parameters were collected and recorded, including plaque index, periodontal probing depth, clinical attachment loss, gingival index, and tooth count of bleeding of probing.

RESULTS

There was a significant difference in plaque index (PLI) between the OSF group (2.14+/-0.64) and the control group (1.7+/-0.89) (P<0.01). Periodontal probing depth (PD) was (1.98+/-0.70) mm in the control group, and (5.57+/-2.39) mm in the OSF group, with significant difference in PD (P<0.01). There was no significant difference in clinical attachment loss, gingival index, and tooth count of bleeding on probing between the 2 groups (P>0.05).

CONCLUSION

OSF patients tend to accumulate plaque, and have deep periodontal pocket, periodontal inflammation or severe periodontal damage.

Complete Spontaneous Remission of an Aggressive Non-Hodgkin's Lymphoma with Primary Manifestation in the Oral Cavity

A well-documented case of complete spontaneous remission of a histopathologically supported highly malignant B-cell Non-Hodgkin's lymphoma with primary manifestation in the oral cavity is presented. This regression, which has showed no signs of recurrence for more than 18 months, occurred following a diagnostic biopsy and without any therapeutic intervention. This report is followed by a short review on the literature upon spontaneous remission on Non-Hodgkin's-Lymphoma.

Localized morphoea associated with oral submucous fibrosis

Localized morphoea is a disease characterized by localized sclerosis of the skin. The disease has been associated with several skin diseases. The case documented here is the first of its kind in which localized plaque type morphoea was seen in a patient with long standing oral submucous fibrosis.

Importance of Coronoidotomy and Masticatory Muscle Myotomy in Surgical Release of Trismus Caused by Submucous Fibrosis

Thirty patients with trismus resulting from betel nut chewing-induced oral submucous fibrosis were treated with either fibrotic tissue release only (group I) or fibrotic tissue release in combination with masticatory muscle myotomy and coronoidotomy (group II). The latter procedures were only performed in patients whose intraoperative interincisal distance remained less than 35 mm immediately after submucous fibrous tissue release. There were eight and 22 patients in groups I and II, respectively. In group I patients, the average intraoperative interincisal distance improved from 19.5 mm to 42 mm. In group II patients, the average intraoperative interincisal distance improved from 13.5 mm to 27 mm after fibrotic tissue release and further improved to 40 mm after masticatory muscle myotomy and coronoidotomy. At an average follow-up of 22.1 months (range, 7 to 70 months), the group I and II patients had an average interincisal distance of 41.5 mm (range, 35 to 50 mm) and 32.9 mm (range, 20 to 42 mm), respectively. These results demonstrate the efficacy of submucous fibrotic tissue release in treating trismus resulting from betel nut chewing-induced submucous fibrosis and confirm the role of additional masticatory muscle and coronoidotomy in treating its severe forms.

Facial Candida albicans cellulitis occurring in a patient with oral submucous fibrosis and unknown diabetes mellitus after local corticosteroid injection treatment

Facial cellulitis caused by odontogenic bacterial infection is frequently encountered; however, facial cellulitis caused by Candida albicans infection is rarely found. A patient with oral submucous fibrosis (OSF) and unknown diabetes mellitus (DM) was treated in our out-patient dental clinic by biweekly submucosal injection of 40 mg triamcinolone acetonide into bilateral buccal mucosae plus forced mouth opening performed by the two hands of the clinician. The interincisal distance of the patient improved from 28 to 48 mm after four times of steroid injection. The symptoms and signs of OSF also improved markedly. Unfortunately, facial candidal cellulitis occurred 2 months after the last time of steroid injection treatment. The infection was cured by incision and drainage, intravenous administration of amphotericin B (100 mg once a day for a week), and an appropriate medical control of DM. No recurrence of facial cellulitis was found during the follow-up period of 18 months. To prevent the occurrence of facial cellulitis after a high-dose steroid therapy, some prophylactic procedures should be taken before the initiation of the steroid treatment.

p53 aberrations in oral sub mucous fibrosis and oral cancer detected by immunohistochemistry

Study of expression of p53 oncoprotein in several precancerous and cancer have been done, but only one literature is available regarding p53 expression in Oral Sub Mucous Fibrosis (OMSF), hence this study was taken up (i) to determine the expression of aberrant p53 in Oral Sub Mucous Fibrosis (OSMF) and Oral Squamous cell carcinoma (SCC) patients. (ii)To study correlation if any between p53 expression and degree of dysplasia in OSMF and SCC patients and (iii)To study correlation if any between p53 expression and habits in OSMF and SCC patients. Study Design consists of biopsy specimens of 38 cases of OSMF and 37 cases of Squamous cell carcinoma were subjected for staining by immunohistochemistry for p53 protein using LSAB visualization system kit. Clinical details along with habits were recorded and the data analyzed with t- test and chi- square test. Results of the study reveals 18 cases of OSMF and 26 cases of SCC were positive for p53 protein. Only 4 cases of SCC showed (++)grade and the rest all had (+)grade. Out of 75 patients, 65 had the habit of smoking and chewing, 4 patients history of habit was not known. Among patients with habits (65), 40 specimens were +ve for p53 stain and 2 out of 6 without history of habit, 2 out of 4 unknown history of habit took up p53 stain. To conclude study showed higher percentage of p53 positive cells in oral cancer cases when compared to oral sub mucous fibrosis cases. It suggests p53 expression may correlate with increase in dysplasia or malignant transformation. Both smoking and chewing habits had a significant role in p53 positive expression.

Morphohistometric analysis of advancing tumor fronts in malignancies associated with oral submucous fibrosis

The objective of this study was to address retrospectively the invasive tumor fronts of epithelial neoplasms associated with OSF and non-associated tumors. Review of a data base of 25 OSF patients who have had concurrent oral squamous cell carcinoma served as the test sample. The controls constituted an equal number of age standardized (roughly) squamous cell carcinomas, non-associated with OSF. The diagnsis and grading were performed based on established criteria. Altogether a total of 8 histopathological variables were evaluated related to the advancing tumor fronts. After selection of cut-off levels, single parameter analysis by means of univariate test revealed significant result in none. A Total Malignancy Score (TMS) of 14.98 and 15.13(mean) were recorded for test and control respectively. Multivariate analysis showed that degree of nuclear plemorphism (p=0.015) and the pattern of invasion (p=0.003) were the only two variables which significantly affected the TMS. OSF associated tumors did not show features unique to it and therefore its response to therapy need not vary significantly from conventional cases.

Total oral reconstruction for cancers associated with advanced oral submucous fibrosis

The progression of submucous fibrosis to oral cancer is well established. This condition in an advanced stage causes progressive trismus. Oral cancers associated with severe submucous fibrosis (interincisor distance [IID] < or = 1.5 cm) require bilateral buccal mucosal reconstruction after tumor excision. After wide excision of the tumor, a regional flap is used to reconstruct the buccal mucosal loss on that side. The opposite buccal mucosa, afflicted by advanced submucous fibrosis, is released at the same time to open the mouth and is resurfaced by an ipsilateral, inferiorly based nasolabial flap. This helps to rehabilitate the oral cavity completely and to prevent the recurrence of trismus. In 18 months, 12 patients underwent total reconstruction of intraoral tumors associated with submucous fibrosis. The average preoperative IID was 0.875 cm. All patients had inferiorly based, two-stage nasolabial flaps for submucous fibrosis reconstruction. The average pain-free postoperative IID was 3.13 cm.

Histologic examination of pedicled buccal fat pad graft in oral submucous fibrosis

PURPOSE

This report evaluates the wound healing process of buccal fat pad (BFP) grafted on a defect of the buccal mucosa for oral submucous fibrosis (OSF).

PATIENTS AND METHODS

Sixteen patients with limitation of mouth opening under the diagnosis of OSF were surgically treated by cutting the fibrotic bands on the buccal mucosa (10 bilateral and 6 unilateral). The defects created were then covered by a BFP graft. The bulging BFP was trimmed postoperatively on a weekly basis until it was fully epithelialized. The specimens were stained and examined microscopically.

RESULTS

Inflammatory cell infiltrate, blood vessel congestion, and fibrinous exudates covering the BFP were obvious by week 2. At week 3, blood vessel congestion and fat cell number decreased markedly. Evidence of stratified squamous epithelium with parakeratosis was seen in the margin of the BFP graft. At week 4, the number of fat cells decreased significantly and the original BFP was almost completely replaced by granulation tissue. The original BFP was fully covered by stratified squamous epithelium by week 5.

CONCLUSIONS

The BFP graft has been widely used for covering exposed defects created by fibrotic band excision for the improvement of mouth opening limitation. The healing process was documented microscopically by weekly observation.

Oral administration of milk from cows immunized with human intestinal bacteria leads to significant improvements of symptoms and signs in patients with oral submucous fibrosis

BACKGROUND

Previous studies have shown that the local and systemic upregulation of fibrogenic cytokines and downregulation of antifibrotic cytokine are central to the pathogenesis of oral submucous fibrosis (OSF). The milk from cows immunized with human intestinal bacteria (immune milk) contains an anti-inflammatory component that may suppress the inflammatory reaction and modulate cytokine production. Therefore, it was decided to test whether immune milk may have some beneficial effects on controlling the symptoms and signs in OSF patients.

METHODS

In this preliminary study, 26 OSF patients who received immune milk treatment (45 g of immune milk powder twice a day) for 3 months and oral habit intervention were included in the experimental group. Another 20 OSF patients who received only oral habit intervention served as the control group.

RESULTS

We found that the interincisor distance was significantly improved (> or =3 mm of the baseline measurement) in 18 of the 26 (69.2%) OSF patients in the experimental group at exit. However, in the control group none of the OSF patients had an increase in interincisor distance greater than 2 mm. In addition, disappearance or significant improvement of symptoms at exit was observed in 80% (16/20) of the patients with intolerance to spicy foods (P < 0.001) and 72.2% (13/18) of the patients with xerostomia (P < 0.005) in the experimental group, compared with 17.6% (3/17) of the patients with improvement of intolerance to spicy foods and 15.4% (2/13) of the patients with improvement of xerostomia in the control group. Partial regression of concomitant oral leukoplakia or erythroplakia (judged from the size reduction of the lesions) at exit was noted in 71.4% (5/7) of the patients in the experimental group (P < 0.05), compared with none (0/5) of the patients with improvement in the control group.

CONCLUSION

We conclude that oral administration of immune milk leads to significant improvements of symptoms and signs in OSF patients.

Visceral organ involvement is infrequent in oral submucous fibrosis (OSF)

Associated visceral organ involvement evidence by systemic fibrosis has not been explored in oral submucous fibrosis (OSF). The investigations in this aspect were limited to loco-regional sites of naso/oropharynx and oesophagus. The study of whether the oral fibrosis is part of a systemic spectrum of disease involving multiple organs is an interesting pursuit. With this intention the patients diagnosed on clinical and histological grounds for OSF were concurrently tested by biophysical means for the presence of endomyocardial fibrosis (EMF), pancreatic (PF) and retroperitoneal fibrosis (RPF), which are endemic to the area studied. Twenty-five (n = 25) cases of OSF who visited the Department of Oral pathology & Microbiology. Govt. Dental College, Trivandrum, India for symptomatic relief of their illness comprised the study group. Ten (n = 10) age and sex matched healthy volunteers comprised the control. All the subjects have had undergone cardiologic and gastrointestinal investigations to rule out the possibility of concurrent EMF and PF. The patients were all of Indian ethnic extraction and mostly (> 90%) were from low socio economic classes. The mean age of the patients was 54.16 +/- 14.6 years, including 18 females and 7 males (F:M = 2.57:1). The severity of fibrosis was unrelated to the age of patients (P > 0.05). All the patients were chewers of areca quid (12%)/tobacco (88%). In addition to quid chewing 3/25 (12%) patients smoked 'bidi' and 6/25 (24%) consumed home brewed liquor (arrack/toddy) which contain about 40-50% ethanol. Statistically no relationship was observed between the clinical stages of OSF and severity of epithelial dysplasia in this study (P > 0.05). Out of the 25 patients, 5 (20%) showed sclerotic aortic value which may be an age related finding. Also 7 (28%) patients were found to be hypertensive and interstitial lung disease was present in 2 (8%). The possibility of EMF in one female patient who showed thickened RV apical endocardium was ruled out by cardiac catheterisation. Thus none of the patients showed evidence of endomyocardial fibrosis. The pancreas was found to be hyperchoic in 8(32 1/4) by ultra sonography. Liver was found to be hyperchoic in 6 (24%). Fat stain in stool samples was found to be positive in 13(58%). The hyperchogenecity of pancreas may be due to alcoholism or an underlying endocrine pancreatic insufficiency like diabetes and not due to pancreatic fibrosis. The positivity of fat stain could be due to fatty liver/alcoholism. Thus the study fails to reveal any evidence of pancreatic fibrosis in the group. The lack of any evidence of an associated visceral organ fibrosis in OSF made it prudent to believe that this is a loco-regional disease, initiated by local factors and propagated under their influence without systemic involvement.

Impact of oral submucous fibrosis on chemotherapy-induced mucositis for head and neck cancer in a geographic area in which betel quid chewing is prevalent

In Southeast Asia and Taiwan, betel quid chewing is prevalent. Patients with head and neck cancer who chewed betel quid habitually seem to experience more severe chemotherapy-induced mucositis in our clinical practice. To validate this issue, patients with untreated head and neck cancer who received cisplatin (cDDP) plus a 5-fluorouracil (5-FU)-based neoadjuvant chemotherapy were included in this analysis. Information on the consumption of betel quid, tobacco, and alcohol were recorded before chemotherapy. Oral submucous fibrosis (OSF) was diagnosed clinically according to the fibrotic appearance of the mucosa and trismus. Mucositis was scored according to the World Health Organization criteria, and the mucositis score of the first course of chemotherapy was used for analysis. From December 1993 to April 1996, 120 patients were enrolled in this trial. Neither the betel quid chewing nor the cancer of the oral cavity was to be a significant factor for mucositis. However, clinically diagnosed OSF was found to display a significant correlation with more severe mucositis (p = 0.02). We concluded that in betel quid chewing-prevalent areas, OSF was a risk factor of more severe mucositis in head and neck cancer patients treated by CDDP and 5-FU-based regimens.

Mouth cancer in India: a new epidemic?

Oral cancer has been traditionally described as a major form of cancer in India although on the basis of cancer registry data, it was thought that the incidence has decreased. There are several recent reports in the literature, however, predicting an increase in mouth cancer incidence in India. This prediction is based upon observation of an increasing prevalence of oral submucous fibrosis, especially in younger individuals, caused by gutka, an industrially manufactured food item. A comparison of the age distribution of recently reported oral submucous fibrosis cases and incident cases reported in the past clearly establishes that the disease is now occurring at much younger ages. A comparison of the age specific incidence rates of mouth cancer (ICD 143-5) during 1983-87 and 1995 in the city of Ahmedabad shows that the incidence has significantly increased in the younger population (< 50 years). Since tongue cancer (ICD 141) does not show a similar increase, it is concluded that the increase in mouth cancer incidence is real. Urgent public health measures are required to curb this new but avoidable epidemic.

Epidemiological survey of oral submucous fibrosis in Xiangtan City, Hunan Province, China

Oral submucous fibrosis is a high risk precancerous condition and is suggested to be caused by areca nut chewing. Areca nut chewing is popular in Hunan Province of China, and is more concentrated in Xiangtan City. Two and nine cases of oral submucous fibrosis (OSF) were first noticed in 1984 and 1985 respectively, and an epidemiologic survey was subsequently performed in 1986. The epidermiologic method of cluster sampling was used. The Yuhu District, one of the five urban districts of the Xiangtan City with a population of 100,000 was selected as a whole body in the survey, 57 independent units of various professions were randomly selected as group samples and more than 70% of subjects in each unit were examined. Definite fibrous band on palpation was used as a main diagnostic criterion for OSF. A total of 11046 individuals were examined; among them were 3907 areca nut chewers (35.37%) and 7139 non-chewers (64.63%). 335 cases of OSF were found, comprising a prevalence rate of 3.03%. The disease involved mainly the middle third of the oral cavity. All of the OSF cases were areca nut chewers. No case had been found in non-chewers. Four cases of oral carcinoma were found on the basis of OSF, the malignant transformation rate was 1.19%. The high prevalence of OSF may be due to areca nut chewing plus extensive and heavy use of hot pepper in Xiangtan people. The result supports the role of the areca nut as an etiologic factor in the development of OSF. The low malignant transformation rate of 1.19% compared with the 7.6% in an Indian report may be because Xiangtan people chew areca nut without tobacco.

Application of the buccal fat pad to the surgical treatment of oral submucous fibrosis

The pedicled buccal fat pad has been widely used for the repair of oral defects. A new application of this flap in the treatment of patients suffering from trismus caused by oral submucous fibrosis is reported. The patients underwent incision of the fibrotic bands and coverage of the buccal defect with a pedicled buccal fat pad flap. The surgical technique is described, and the results suggest that this is a logical, convenient, and reliable technique for the treatment of oral submucous fibrosis.

Role of areca nut in the causation of oral submucous fibrosis: a case-control study in Pakistan

A case-control study on chewing and smoking habits and oral submucous fibrosis (OSF) was undertaken in Karachi in 1989/90. Cases were patients detected with fibrous bands and leathery mucosa and hospital-based controls were matched by age and sex. Information on habits was collected by personal interview of 157 cases and 157 controls. Despite overall female preponderance, a substantial number of young men were enlisted. The male/female risks were found to be similar. Immigrants from India to Pakistan (Mohajir) had a similar risk status to local Punjabis. No differences between risks were found when comparing the three age categories, 21, 21-40, 41-60 yr. Among the cases, an increased risk was observed for areca nut chewing. This habit when practised alone appeared to have the highest risk (RR 154), followed by pan with or without tobacco (RR 64, 32 respectively). Logistic regression and discriminant analysis showed that daily consumption rates appeared to be more important with respect to risk than lifetime duration of habit. Tobacco habits were more prevalent amongst those 15 cases who presented with concurrent carcinoma and OSF: We conclude that areca nut chewing has a causal relationship with OSF: additional tobacco insult may be necessary for subsequent carcinoma development.

Electrogustometry in oral submucous fibrosis. A study in 50 cases

Taste sensation were evaluated in 50 cases of Oral Submucous Fibrosis. Ankyloglossia was present in 28% and ulceration of tongue in 6% of cases. None of the cases had subjective impairment of taste sensation. Electrogustometry revealed impairment of taste in 46% of cases. Ankyloglossia was found to be related with the severity of Oral Submucous Fibrosis but impairment of taste was not related with the severity of the disease. The possible mechanism of the impairment of taste is discussed in brief.

Surgery for severe trismus in submucous fibrosis

Bilateral full thickness naso-labial flaps have been used successfully in three patients to give long-term relief of the severe trismus caused by oral submucous fibrosis. The flaps are set into defects created by incision of the oral mucosa. The postoperative rehabilitation compared favourably with other methods and we now advocate the technique for all cases of submucous fibrosis requiring correction of severe trismus.