Assessment of oral health-related quality of life instruments for oral submucous fibrosis: A systematic review using the COnsensus-based Standards for the selection of health Measurement Instruments (COSMIN) checklist

Quality of life (QoL) instruments are becoming increasingly important in research and often used in clinical practice. Various QoL instruments have been developed/ validated for assessment of oral health-related QoL (OHRQoL) in patients with oral submucous fibrosis (OSF). Selection of an adequate instrument is challenging in routine practice due to lack of information on psychometric quality of measurement instruments. This systematic review gives an extensive overview of quality of all the currently available measurement instruments for use in OSF patients. PubMed, Scopus, Web of Science and CINAHL were searched for relevant literature until December 2018 and the information was extracted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The quality of the identified studies was assessed per measurement property according to the COnsensus-based Standards for the selection of health Measurements Instruments (COSMIN) checklist. Four studies that met the inclusion criteria were included. Three generic and one disease-specific QoL instruments were identified. Information regarding important measurement properties was often incomplete. The evidence for the quality of measurement instruments was found to be variable, none of the instruments performed sufficient on all measurement properties. Based on the available information, OHRQoL-OSF appeared to have adequate COSMIN measurement properties. As recently published, newer QoL instruments have not yet been evaluated in an adequate manner for use in OSF. We suggest future studies should implement OSF-specific OHRQoL-OSF to better understand OSF patients' perspectives and help inform clinicians to propose treatment strategies as per patients' needs.

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.

Sphingosine-1-phosphate stimulated connective tissue growth factor expression in human buccal fibroblasts: Inhibition by epigallocatechin-3-gallate

BACKGROUND/PURPOSE

Connective tissue growth factor (CCN2) has been associated with the pathogenesis of various fibrotic diseases, including oral submucous fibrosis (OSF). The chemical constituents of areca nut along with the mechanical trauma cause OSF. The coarse fibers of areca nut injure the mucosa and hence sphingosine-1-phosphate (S1P) is released at the wounded sites. Recent studies have shown that S1P is involved in wound healing and the development of fibrosis. The aims of this study were to investigate the effects of S1P on CCN2 expression in human buccal fibroblasts (HBFs) and identify the potential targets for drug intervention or chemoprevention of OSF.

METHODS

Western blot analyses were used to study the effects of S1P on CCN2 expression and its signaling pathways in HBFs and whether epigallocatechin-3-gallate (EGCG), the main and most significant polyphenol in green tea, could inhibit this pathway.

RESULTS

S1P significantly enhanced CCN2 synthesis in HBFs. This effect can be inhibited by c-Jun NH2-terminal kinase (JNK) inhibitor and extracellular signal-regulated kinase inhibitor but not by P38 mitogen-activated protein kinase inhibitor. Interestingly, EGCG completely blocked S1P-induced CCN2 expression via suppressing S1P-induced JNK phosphorylation.

CONCLUSION

S1P released by repetitive mechanical trauma during AN chewing may contribute to the pathogenesis of OSF through upregulating CCN2 expression in HBFs. EGCG could be an adjuvant to the current offered therapy options or the prevention of OSF through suppression of JNK activation.

A light microscopic study of fibrosis involving muscle in oral submucous fibrosis

Oral submucous fibrosis (OSF) is a common pre-malignant condition of the mouth in arecanut chewers in Indian subcontinent. It is characterized by restriction in opening of the mouth, tongue protrusion, and cheek flexibility. Reports of muscle changes in OSF, using light microscopy are few. Incisional biopsy sections of thirty OSF patients were stained with Masson's Trichrome stain, to study the fibrosis involving the muscle. Wide spectrum of changes were observed where fibrosis was being evident sub-epithelially, not extending in to the muscle to cases where only a few remnants of muscle fibers were seen and the missing muscle bundle area being replaced by fibrous tissue. The probable mechanism by which these changes occur is discussed.

Pentoxifylline therapy : A new adjunct in the treatment of oral submucous fibrosis

OBJECTIVE

This study was designed to determine the effect of pentoxifylline (Trental) on the clinical and pathologic course of oral submucous fibrosis. This drug is a methylxanthine derivative that has vasodilating properties and was envisaged to increase mucosal vascularity.

STUDY DESIGN

This investigation was conducted as a randomized clinical trial incorporating a control group (Standard drug group SDG, multivitamin, and local heat therapy) in comparison to pentoxifylline test cases (Experimental drug group EDG, 400mg 3 times daily, as coated, sustained release tablets). The stipulated treatment period was 7 months and a total of 29 cases of advanced fibrosis (14 test subjects and 15 age and sex matched diseased controls) were included in this study and 100% compliance was reported at the end ofthe test period.

RESULTS

Mild gastric irritation that could be managed by diet protocols was the only untoward symptom reported during this trial. Review of the patients and controls was done at an interval of 30 days and subjective and objective measurements were recorded. The follow up data at each visit with respect to each other and to base-line values was calibrated using a nonparametric test of Mann-Whitney (Kruskal-Wallis test). Significant comparisons with regard to improvement were recorded as objective criteria of mouth opening (t=11.285, p= 0.000), tongue protrusion (t= 3.898, p = 0.002), and relief from perioral fibrotic bands (p = 0.0001554). Subjective symptoms of intolerance to spices (p = 0.0063218), burning sensation of mouth (p = 0.0005797), tinnitus (p=0.000042), difficulty in swallowing (p=0.0000714). and difficulty in speech (p=0.0000020) were also recorded significant improvement at the end of the trial period.

CONCLUSION

This pilot investigation points to the effectiveness of pentoxifylline as an adjunct therapy in the routine management of oral submucous fibrosis.

A scoring system for the early detection of oral submucous fibrosis based on a self-administered questionnaire

OBJECTIVES

The aims of the present study were to evaluate the frequent clinical complaints of oral submucous fibrosis (OSF) and to develop a scoring system for early detection of the disease by a self-administered questionnaire.

METHODS

A total of 296 subjects were recruited, including 123 OSF patients without oral cancer and 173 betel quid chewers without OSF or oral cancer. A self-administered questionnaire was used to collect the symptom profile from study subjects. Their maximal mouth opening (MMO) between upper and lower incisor edges was measured and recorded by well-trained nurses. A binary logistic regression model examining the likelihood of OSF based on the eight symptoms of interest was used to develop the scoring system.

RESULTS

Among 79 OSF subjects with an MMO < 35 mm, the most frequent complaint was trismus (87.3%), followed by burning sensation (76.0%) and xerostomia (72.2%). Among 44 OSF subjects with an MMO > or = 35 mm, burning sensation (68.2%) was the most frequent complaint, followed by trismus (54.5%) and xerostomia (54.5%). Six frequent complaints including trismus, burning sensation, xerostomia, sore throat, numbness, and oral ulceration were utilized to develop a scoring system for the early detection of OSF. The scoring system had an area under the receiver operating characteristic curve of 0.90.

CONCLUSION

This study suggests a screening questionnaire of frequent complaints for the early detection of OSF.

High incidence of autoantibodies in Taiwanese patients with oral submucous fibrosis

BACKGROUND

Previous study has shown a high incidence of autoantibodies including antinuclear (ANA), antismooth muscle (SMA), antigastric parietal cell (GPCA), antithyroid microsomal (TMA), and antireticulin antibodies in a small group of 26 patients with oral submucous fibrosis (OSF). The reasons why some of the OSF patients have high titers of autoantibodies in serum have not been completely explained and no further study on autoantibodies in OSF patients has been done in a large group of patients.

METHODS

In this study, we determined the serum levels of ANA, SMA, GPCA, and TMA in a large group of 109 male Taiwanese patients with OSF by an indirect immunofluorescence technique (for ANA, SMA, and GPCA), and by a semiquantitative microtiter particle agglutination test (for TMA). The presence of serum autoantibodies in OSF patients was further correlated with patients' oral habits and the severity of OSF measured by maximum mouth opening (MMO) and sites of involvement.

RESULTS

We found that the frequencies of presence of serum ANA (23.9%), SMA (23.9%), and GPCA (14.7%) in OSF patients were significantly higher than those (9.2, 7.3, and 5.5%, respectively) in healthy control subjects (P < 0.01, P < 0.005, and P < 0.05, respectively). Although the frequency of presence of TMA (5.5%) in OSF patients was also greater than that (2.8%) in healthy control subjects, the difference was not significant (P > 0.05). The presence of serum GPCA in OSF patients was significantly associated with daily areca quid (AQ) consumption (P < 0.05). The presence of serum ANA in OSF patients associated with daily AQ consumption was of borderline statistical significance (P = 0.066). However, no significant correlations were demonstrated between the presence of serum autoantibodies in OSF patients and other variables of oral habits, MMO, and sites of involvement.

CONCLUSION

In this study, all the 109 OSF patients had AQ chewing habit and 73.4% of the OSF patients swallowed the 'juice' of AQ during the chewing process. The presence of serum GPCA and ANA in OSF patients was associated with daily consumption of AQs. AQ chewing caused mucosal microtrauma, and ulcerations facilitated the diffusion of genotoxic and cytotoxic AQ ingredients into the oral and gastric tissues. Altered autoantigens released from AQ ingredients-damaged cells may induce autoantibody production. Higher frequencies of specific HLA-DR antigens in OSF patients may also help autoantibody production. Therefore, we conclude that the high incidence of autoantibodies in OSF patients may be due to AQ chewing habit, toxic AQ ingredients, and genetic susceptibility of the OSF patients.

Clinical and functional staging of oral submucous fibrosis

OBJECTIVE

To investigate the association of location of bands in oral submucous fibrosis and extent of mouth-opening.

DESIGN

Cross-sectional study.

SETTING

University hospital, Pakistan.

SUBJECTS

325 patients who presented with oral submucous fibrosis in Karachi between January 1992 and October 1994, of whom 288 had data sufficient for analysis.

MAIN MEASURES

Location of fibrous bands in the mouth and interincisal distance (mm).

RESULTS

All subjects with labial bands had bands in the fauces, and all but one who had labial bands also had buccal bands. All those with buccal bands also had bands in the fauces. Of those with buccal bands, 42% did not have labial bands. The proportion of patients with bands in all three sites increased from functional stage A (interincisal opening < or = 10 mm) to stage C (interincisal opening > or = 20 mm) with a simultaneous reduction in the proportion of people with bands in one or two sites (X2 = 105, df = 4, P < 0.0001).

CONCLUSIONS

Bands are common at the back of the mouth in mild cases of oral submucous fibrosis and, as the disease increases in severity, are more likely to be found anteriorly as well.

Establishing a normal range for mouth opening: its use in screening for oral submucous fibrosis

The maximal mouth opening of 700 healthy Nepalese adults, age range of 18-68 years, measured by paraclinical workers was determined as there are no data available for an Asian population. The mean value of the inter-incisal distance was 47.1 mm (range 33.7-60.4 mm) and 98% of the population surveyed fell within this range. The minimum limit of normal oral opening was determined to be 34 mm. Ten out of 13 patients with histologically confirmed oral submucous fibrosis (OSF) had a maximal oral opening of less than 34 mm. It was concluded that reduced oral opening measured by paraclinical workers as a single screening test for oral submucous fibrosis, has a sensitivity of only 77% and will detect only advanced cases. However, each of the 3 subjects from the healthy population found to have restricted mandibular opening and who agreed to be examined further had significant oral conditions, namely oral submucous fibrosis (2) and pericoronitis (1). The study confirms the value of this measurement as a screening procedure for significant oral disease by paraclinical staff particularly in developing countries where trained dental and medical personnel are scarce. Because of its limited sensitivity, measurement of mouth opening is unsatisfactory as a single screening test for OSF, as it will not detect early stages of the disease.

Oral submucous fibrosis. A review

Oral submucous fibrosis (OSF) affects an estimated 2.5 million people, mostly in the Indian subcontinent. Limitation of oral opening resulting in difficulty in eating is the main presenting feature. Although nutritional deficiencies and immunological processes may play a part in the pathogenesis, the available epidemiological evidence indicates that chewing betel quid (containing areca nut, tobacco, slaked lime or other species) is an important risk factor for OSF. Genetically determined susceptibility could explain why only a small fraction of those using betel quid develop the disease. In OSF there is an incidence of oral cancer of 7.6 per cent for a median 10-year follow-up period. Risk markers for malignant transformation in OSF include epithelial dysplasia, silver binding nucleolar organizer region counts, and sister-chromatid exchange frequencies; p53 tumour suppressor gene mutations may be involved in these potentially malignant changes.

Oral stent as treatment adjunct for oral submucous fibrosis

Oral submucous fibrosis is a chronic inflammatory disease that results in progressive juxtaepithelial fibrosis of the oral soft tissues that can cause increasing difficulty in chewing, swallowing, speaking, and mouth opening. Many treatment regimens for oral submucous fibrosis have been proposed to alleviate the signs and symptoms of the disorder. In severe cases, surgical intervention is the only treatment modality, but relapse is a major problem. This article describes the use of an oral stent as an adjunct to surgery to prevent relapse.

Oral submucous fibrosis in a 4-year-old girl

A rare case of oral submucous fibrosis in a 4-year-old Indian girl is presented. The condition is defined, and the clinical and laboratory features are discussed. Different treatment modalities and current theories of etiology are presented. Finally, the importance of regarding this condition as a precancerous lesion is supported.