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MANAGEMENT OF ORAL SUBMUCOUS
FIBROSIS
PRESENTED BY
DR.PANKAJ GUPTA
PG STUDENT
DEPT.OF OMDR
CONTENTS
 Introduction
 Prevalance ,age ,gender
 Etiopathogenesis
 Classification
 Clinical features
 Management
 References
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Introduction
• Oral submucous fibrosis is defined as “An insidious chronic
disease affecting any part of the oral cavity and sometimes the
pharynx. It is always associated with juxta-epithelial
inflammatory reaction followed by fibroelastic changes of the
lamina propria with epithelial atrophy leading to stiffness of
the oral mucosa and causing trismus and inability to speak”.
Pindborg and Sirsat in 1966.
• The disease is exclusively reported in Indian population and
in South East Asia, but the cases have been reported
worldwide like Kenya, China, UK, Saudi Arabia and other
parts of the world where Asians have migrated and are
migrating.
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• It has been linked with an increased risk of malignancy.
• A wide range of treatment including drug therapy, surgical
therapy, and physiotherapy have been attempted till date, with
varying degrees of benefit, but none have been able to cure
this disease.
• The treatment depends on the level of clinical involvement. At
a very early stage, cessation of the habit is adequate.
Medical/surgical treatment is necessary for moderate to severe
cases. Surgical treatment is the method of choice in patients
with marked limitation of mouth opening or in patients not
responding to the conservative management.
Prevalence
• Worldwide, estimates of OSMF shows a confinement to
Indians and Southeast Asians with 0.2-1.2% of an urban
population attending dental clinics are affected by OSMF.
• Ali FM, Aher V, Prasant M C et al. Oral submucous fibrosis: Comparing
clinical grading with duration and frequency of habit among areca nut
and its products chewers. J Can Res Ther 2013;9:471-6.
• The age range of patients with OSMF is wide,most common
between 20 and 40 years of age.
• Age group below 20 years of age more often contract OSMF.
Rajendran R, Sugathan C, Remani P, Ankathil R,
Vijayakumar T. Cell mediated and humoral immune responses in oral
submucous fibrosis. Cancer.1986;58(12):2628-31.
Greenberg MS, Glick M, Ship JA. Burket’s Oral
Medicine.11th edition.Ontario:BC Decker Inc;2003.p. 88-89
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Gender
The prevalence in indian population is 5% for women and 2 % for
men.
Greenberg MS, Glick M, Ship JA. Burket’s Oral
Medicine.11th edition.Ontario:BC Decker Inc;2003.p. 88-89
Malignant transformation
• Malignant transformation rate of OSMF was found to be in the
range of 7-13% and incidence over a 10 year period is 8%.
Greenberg MS, Glick M, Ship JA. Burket’s Oral
Medicine.11th edition.Ontario:BC Decker Inc;2003.p. 88-89
• According to long-term follow-up studies, a transformation rate
of 7.6% over a period of 17 years was reported.
Tilakaratne WM, Klinikowski MF, Saku T, Peters TJ,
Warnakulasuriya S. Oral submucous fibrosis: Review on etiology and
pathogenesis. Oral Oncol.2006;42:561-8
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Etio-pathogenesis
 Areca nut/betel nut
 Tobacco and lime
 Nutritional deficiencies
 Immunological disorders
 Collagen disorders
 Capsasin(a prime component in chillies)
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Immunological disorders
Increased levels of serum IgA
Hyperglobulinaemia, imbalance in immuno-regulation and
alteration in local tissue architecture.
R.Rajendran. Oral submucous fibrosis:
etiology, pathogenesis, and future research. Bulletin of the WHO. 1994;
72(6): 985-996.
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Collagen disorder
Increased collagen production
1)Activation of procollagen genes
2)Elevation of pro-collagen proteinase levels
3) Up-regulation of lysyl –oxidase(LOX) activity
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Classification
According to Pindborg in 1989 OSMF is clinically divided into 3
stages, and the physical findings vary accordingly, reported by
Murti, in 1992; Cox in 1996; Aziz in 1997
Stage 1: Stomatitis includes erythematous mucosa
 Vesicles and mucosal ulcers
 Melanotic mucosal pigmentation
 Mucosal petechia.
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Stage 2: Fibrosis occurs in ruptured vesicles and ulcers when
they heal, which is the hallmark of this stage.
 Early lesions demonstrate blanching of the oral mucosa.
 Older lesions include vertical and circular palpable fibrous
bands in the buccal mucosa and around the mouth opening or
lips, resulting in a mottled, marble like appearance of the
mucosa because of the vertical, thick, fibrous bands running in
a blanching mucosa.
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• Reduction of the mouth opening
• Stiff and small tongue.
• Blanched and leathery floor of the mouth.
• Fibrotic and depigmented gingiva.
• Rubbery soft palate with decreased mobility.
• Blanched and atrophic tonsils.
• Shrunken bud like uvula.
• Sinking of the cheeks, not commensurate with age or
nutritional status
Stage 3: Squealae of OSMF are as follows:
• Leukoplakia is precancerous and is found in more than 25%
of individuals with OSMF.
• Speech and hearing deficits may occur because of
involvement of the tongue and the eustachian tubes.
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Khanna and Andrade in 1995 developed a group classification
system for the surgical management of trismus
• Group I: Earliest stage without mouth opening limitations
with an interincisal distance of greater than 35 mm.
• Group II: Patients with an inter-incisal distance of 26-35 mm.
• Group III: Moderately advanced cases with an interincisal
distance of 15-26 mm. Fibrotic bands are visible at the soft
palate, and pterygomandibular raphe and anterior pillars of
fauces.
• Group IVA: Trismus is severe, with an interincisal distance of
less than 15 mm and extensive fibrosis of all the oral mucosa.
• Group IVB: Disease is most advanced, with premalignant and
malignant changes throughout the mucosa.
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Clinical features
 Blanching, i.e., marble-like appearance of the oral mucosa
and stiffness of the oral mucosa.
 Trismus
 Burning sensation in the mouth when consuming spicy
food.
 Intolerance to eating hot and spicy foods.
 Appearance of blisters especially on the palate, ulcerations.
or recurrent generalized inflammation of the oral mucosa.
 Reduced mobility of the soft palate and tongue
 Defective gustatory sensation and dryness of the mouth.
15
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Clinical picture showing:
A. Marble-like appearance of
soft palate, faucial pillars &
upper pharyngeal mucosa
B. shrunken uvula, blanching
of left buccal mucosa &
retromolar region
C. Fibrosis & depapillation of
tongue.
D. Blanching of right buccal
mucosa
E. Fibrosis & pigmentation of
lower lip
Management of OSMF
• Preventive measures - Discontinuation of Habit and
Counselling
• Nutritional support
• Physio-therapy:
Kneading
Muscle stretching exercises
Heat –Short wave/Micro wave diathermy
• Medical management
• Ultrasound and laser therapy
• Surgical therapy
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Preventive measures - Discontinuation of Habit and
Counseling
 The preventive measure should be in the form of stoppage of
the habit of areca nut chewing.
 Patients should be explained about the condition and its
probable malignant potential and counselling should be given
for de-addiction.
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Role of Areca nut in OSMF
• The alkaloids and flavonoids from the areca nut are absorbed
and undergoes metabolism. These alkaloids undergo
nitrosation and give rise to nitrosamines, which might have a
cytotoxic effect on cells.
• Additionally, these constituents of areca nut and their
metabolites are a source of constant irritation to oral tissues.
• Furthermore, the micro trauma produced by the friction of
rough of areca nut fragments also facilitates the diffusion of
alkaloids and flavonoids into the subepithelial connective
tissue, resulting in juxtaepithelial inflammatory cell
infiltration. .
Chiang CP, Hsieh RP, Chen TH et al. High
incidence of autoantibodies in Taiwanese patients with oral submucous
fibrosis. J Oral Pathol Med 2002; 31: 402–9.
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Oral mucosa
Betel quid
Constant irritation
Chronic inflammation
Activated T cell and macrophages at the site
Increase in cytokines IL 6, TNF, Ifa, increase in growth
factor TGF-β
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• The two main pathways regulated by TGF-β are collagen
production pathway and collagen degradation pathway, along
with the chemical constituents present in areca nut.
Increased collagen production
1)Activation of procollagen genes
2)Elevation of pro-collagen proteinase levels
3) Up-regulation of lysyl –oxidase(LOX) activity
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DECREASED COLLAGEN DEGRADATION
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Rajlalitha PV . S.Molecular pathogenesis of oral submucous fibrosis – A
collagen metabolic disorder. J Oral Pathol Med .2005 ;34: 321–8
• Studies have supported that by showing that early
discontinuation of the habit will result in improved clinical
outcomes.
• A study carried out on 27600 individuals in ernakulam,kerala
aged 15 years and above. OSMF was diagnosed and biopsied
was performed.Follow up was done annually to determine
malignant transformation rates and natural history of the
disease.The results showed that after 17 years,Cancer
developed in 5 patients,all of them had the habit of chewing
tobacco and areca nut with betel leaves and lime.
Murti PR et al. Malignant transformation rate in oral
submucous fibrosis over a 17-year period. Community Dent Oral
Epidemiol. 1985 Dec;13(6):340-1
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• A dose-dependent relationship was observed for both
frequency and duration of chewing areca nut in the
development of OSMF.
• In a study ,highest incidence of OSMF with increasing
severity was associated with those who chew areca nut more
than 10/ day for more than 5-10 min.
Tilakaratne WM, Klinikowski MF, Saku T, Peters TJ,
Warnakulasuriya S. Oral submucous fibrosis: Review on aetiology and
pathogenesis. Oral Oncol. 2006;42:561–8
• The severity and the time taken for the development of the
disease may also vary according to the preparation of areca
nut consumed.
Ali FM, Aher V, Prasant MC, Bhushan P, Mudhol A,
Suryavanshi H. Oral submucous fibrosis: Comparing clinical grading with
duration and frequency of habit among areca nut and its products
chewers. J Cancer Res Ther. 2013;9:471–6
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 Stoppage of areca nut chewing is foremost important measure
to treat OSMF.
Nicotine Replacement Therapy
• Supplied as a gum, skin patch, nasal spray, or inhaler. It works
by providing a substitute source of nicotine, without the other
harmful components of tobacco.
• Nicotine medications make it easier to abstain from tobacco
by replacing, at least partially, the nicotine formerly obtained
from tobacco and thereby providing nicotine-mediated
neuropharmacologic effects.
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There appear to be at least three major mechanisms of action
by which NRT medications support tobacco cessation efforts.
• Reduce either general withdrawal symptoms or at least
prominent ones.
• Reduce the reinforcing effects of tobacco-delivered nicotine.
• Finally, nicotine medications may provide some effects for
such as sustaining desirable mood and attention states, making
it easier to handle stressful or boring situations, and managing
hunger and body weight gain.
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• Zyban (bupropion hydrochloride) and Chantix (varenicline)
are non-nicotine-containing medications available by
prescription.
• Zyban reduces the symptoms of nicotine withdrawal by acting
on chemicals in the brain related to nicotine cravings. Zyban
is also prescribed under another name “Wellbutrin” to treat
depression.
• Chantix lessens pleasure from smoking and reduces symptoms
of withdrawal.
Available in 2mg ,4mg dose.
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Role of chillies
• The role of chillies (Capsicum annum and Capsicum
frutescence) ingestion in the pathogenesis of OSMF is
controversial. Sirsat in 1960 done a study demonstrated that
the capsaicin in chilies stimulates widespread palatal fibrosis
in rats.
• According to Pillai in 1992 the incidence of OSMF is lower in
Mexico and South America than in India, despite the higher
dietary intake of chilies.
• Pillai R, Balaram P, Reddiar KS. Pathogenesis of oral
submucous fibrosis. Relationship to risk factors associated with oral
cancer. Cancer. Apr 15 1992;69(8):2011-20.
• A hypersensitivity reaction to chilies is believed to contribute
to OSMF.
Aziz SR.Oral submucous fibrosis: an unusual disease. J N J
Dent Assoc.1997. 68: 17–19 .
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• Chilies are thought to irritate the oral mucosa and cause an
inflammatory reaction and along with continued use of chilies
and other spices, continued irritation of the mucosa causes
chronic inflammation which leads to fibrosis formation.
Ahmad MS. Epidemiological and etiological study of
oral submucous fibrosis among Gutkha chewers of Patna, Bihar, India. J
Indian Soc Pedod Prev Dent.2006;84-89.
• Capsaicin, which is vanillylamide of 8-methyl- 6-nonenic
acid, is the active ingredient of chillies, play an etiological
role in oral submucous fibrosis.
R.Rajendran. Oral submucous fibrosis: etiology,
pathogenesis, and future research. Bulletin of the WHO. 1994; 72(6): 985-
996.
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• It may be mentioned that chillies can damage the cells of the
mucosa and if this is continuous, it probably causes chronic
inflammation, which leads to the formation of excessive
fibrosis.
• So chillies have indirect effect on the pathogenesis of OSMF
as hypersensitivity to chillies is often explained as a common
factor in the development of OSMF.
Rajendran R. Oral submucous fibrosis: Etiology,
pathogenesis and future research. Bull WHO 1994;72:985-9
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Nutritional support
• Malnutrition is a major problem for the inhabitants of most
countries where OSMF is prevalent.
• Deficiencies of vitamins and iron have been implicated as
being of etiological importance in OSMF.
• The rationale of giving nutrients in OSMF patients is to
correct deficiency states and promote normal cellular
processes present in health that help to protect against adverse
events including carcinogenesis.
Gupta DCS, Rameshwar D, Iqbal A
.Treatment modalities in oral submucous fibrosis: how they stand
today? Study of 600 cases.1992 .Indian J Oral Maxillofac Surg:
43–47.
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• Supplementing the diet with foods rich in vitamins A, B
complex, and C and iron
• Advice green leafy vegetables, red tomatoes, fresh fruits.
• Advice Green tea
• High protein diet.
Beneficial effects of Vitamin A
• Vitamin A plays a major role in the epithelial differentiation,
in mucous secretary and keratinisation tissues and as well as
in adequate concentration it delays, slows, arrests or even
reverse the progress of premalignant cells to cells with
invasive malignant potential.
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Beta carotene
• In one study, an attempt was made to analyze serum levels of
beta carotene in 45 patients with oral submucous fibrosis and
45 age- and sex-matched controls.The serum beta carotene
level was significantly lower in the patients with OSMF than
in the controls.
• When the values were compared between different disease
stages, the maximum reduction of beta carotene was evident
for Grade III OSMF, as compared with Grade I and II .The
results of the study showed that beta carotene plays an
important role in the pathogenesis of OSMF, and that its level
decreases with disease progression. OSMF patients should be
treated with a diet rich in beta carotene to reduce disease
severity and progression towards malignancy.
Aggarwal A, Shetti A Keluskar V. Bagewadi A.Estimation of serum beta
carotene levels in patients with oral submucous fibrosis in India. J Oral
Sci. 2011 Dec;53(4):427-31.
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 Prevent the oxidation of essential cellular constituents such as
formation of oxidation products.
 Act as scavenger for free radicals.
 Increase the number of circulating lymphocytes.
 Enhance the proliferation and induction of cytotoxic t-cells.
 Increase the no. of helper t-cells and TNF.
Brand names- vitamin A(50000 IU)
• VA(50000 IU)
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• Study by Maher et al. evaluated the efficacy of combination
of micronutrients (vitamins A, B complex, C, D, and E) and
minerals (iron, calcium, copper, zinc, magnesium, and others)
in controlling the symptoms and signs of OSMF. Significant
improvement in symptoms, notably intolerance to spicy food,
burning sensation, and mouth opening was observed.
Maher R, Aga P, Johnson NW, Sankaranarayanan R,
Warnakulasuriya S. Evaluation of multiple micronutrient supplementation
in the management of oral submucous fibrosis in Karachi, Pakistan. Nutr
Cancer. 1997;27:41–7
• Borle et al. reported that Vitamin A, 50,000 IU chewable
tablets, if given once daily could cause symptomatic
improvement. Trismus did not improve with this treatment.
Borle, R.M. and Borle, S.R. Management of oral submucous
fibrosis. Am. Assoc. Oral Maxillofacial Surgeons.1991. 49, 788-791.
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BRAND NAME
CAP.ANTOXID(1 cap.tid for first 2 months and then 1 cap.od )
 Beta Carotene 30 mg, Manganese 2 mg, Copper sul. 1
mg, Zinc Sulphate 27.5 mg, Selenium 200 mcg.
CAP.SM FIBRO
 Lycopene 5 mg+Betacarotene 10 mg +Selenium 75 mcg +zn
sul 27. 5 mg+Copper sul. 1 mg +Alpha lipoic acid 50 mg
+Alpha tocopheryl acetate 10 IU
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The Role of Vitamin-E in Cancer Chemoprevention
• Many past studies suggest the role of antioxidant (vitamin-E)
in treatment of oral mucosal lesions particularly includes oral
leukoplakia, oral lichen planus, oral submucous fibrosis and
oral cancer.
Iqbal et al.Role of Vitamin E in Prevention of Oral Cancer:-A
Review.J Clin Diagn Res. 2014; 8(10): ZE05–ZE07
Main action of vitamin E includes increase immunity, controls
free radicals mediated cell disturbances, maintains membrane
integrity, inhibit cancer cell growth, cytotoxicity.
• Inhibits oral cavity carcinogenesis.
• Reduces the risk of developing oral cancer.
• Prevent development of neurological abnormalities.
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• One study carried out which highlighted the role of Vitamin-E
in oral submucous fibrosis. Plasma Vitamin-E level was found
to be decreased in grade II and III OSMF cases but not in
grade I cases. However, mean Vitamin-E level was found to
be decreased (9.3 ± 0.3 mg/L) as compared to healthy controls
(mean = 10.1 ± 1.2 mg/L). Enzymatic antioxidant defense was
assessed by SOD activity, which did not show any significant
change in any stage of the disease.
Gupta S, Reddy MVR, Harinath BC. Role of oxidative stress
and antioxidants in aetiopathogenesis and management of oral submucous
fibrosis. Indian Journal of Clinical Biochemistry. 2004;19:138–41
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LYCOPENE
 Lycopene is a major carotenoid obtained from tomato with
potent anticancer activity.
 Lycopene is one of the most potent antioxidants, with a
singlet-oxygen-quenching ability twice as high as that of β-
carotene and 10 times higher than that of α-tocopherol.
Actions-
 Inhibition of cancer cell proliferation.
 Interference with GF stimulation of cancer cell proliferation.
 Cancer prevention by inducing phase 1 enzymes(removal of
carcinogenes)
 Regulation of transcription.
 Restoration of gap junctions by upregulating the expression of
connexin (cx43 gene)
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Sanadi et al. lycopene: it’s role in health and disease ,
IJPSR, 2012; Vol. 3(12): 4578-4582
• In one study, 58 were randomly divided into 3 groups,
evaluated weekly over a 2-month period. Patients of group A
(n = 21) received 16 mg of lycopene, those of group B (n =
19) received 16 mg of lycopene along with biweekly
intralesional steroid injections, and those of group C (n = 18)
were given a placebo.
• Results showed that mouth-opening values for the patients
showed an average increase of 3.4 mm, 4.6 mm, and 0.0 mm
for patients in groups A, B, and C, respectively. The authors
concluded that lycopene should be used as a first line of
therapy in the initial management of oral submucous fibrosis.
Kumar A, Bagewadi A, Keluskar V, Singh M. Efficacy of
lycopene in the management of oral submucous fibrosis. Oral Surg Oral
Med Oral Pathol Oral Radiol Endod. 2007 Feb;103(2):207-13
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• In another study included 92 patients with OSMF. Out of 92,
46 patients were given lycopene and remaining 46 were on
placebo drug.
• Lycopene group patients received 8 mg Lycored per day in
two divided doses of 4 mg each, while placebo group patients
received placebo tablet twice a day. Patients were examined
for changes in mouth opening and other clinical symptoms of
OSMF during 3 months and were followed up for next
2months.The results showed that Lycopene was found to be
significantly efficacious in the amelioration of signs and
symptoms of OSMF.
Karemore TV, Motwani M. Evaluation of the effect of newer
antioxidant lycopene in the treatment of oral submucous fibrosis. Indian J
Dent Res 2012;23:524-8
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Dose
 Based on previously reported studies; a daily intake of 25-30
mg lycopene was initially suggested .
Rao V and Heber D, Future directions and
intake recommendations; Caledonian Science Press, Scotland U.K.,
2001, 43
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• A fully randomized, cross-over design was used in this study.
Tomato ketchup used in the study was provided by H.J.Heinz
Company. A standardized single serve pouch of ketchup (8ml)
contained 1 mg of lycopene. Lyc-O-Mato (an oleoresin based
lycopene capsule) Subjects underwent a one-week run-in
period during which they consumed their regular diet, and
maintained a 7-day diet record.
• After 2-week washout phase during which they were asked to
consume their regular diet, but refrained from consuming any
tomatoes, processed tomato products and other sources of
lycopene. Following the washout phase, subjects were asked
to consume one of the test materials (5,10,20 mg) lycopene as
tomato ketchup and 5, 10, 20 mg lycopene as Lyc-O-Mato
capsule) along with their regular diet for 2 weeks. Following
the 2-week treatment period, subjects again underwent a 2-
week washout phase prior to the second treatment phase
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• They did not consume any source of lycopene other than those
provided during the entire period of the study.
• A significant increase in serum lycopene level was observed
for both ketchup and capsules at all levels of intake. Based on
these results an intake of 5 to 10 mg lycopene per day is
recommended.
Rao AV, Shen H (2002). Effect of low dose lycopene intake on
lycopene bioavailability and oxidative stress. Nutr Res 22, 1125–1131.
Brand name-Cap licoray plus- lycopene 2000 mcg.
Lycomin-lycopene 5000 mcg,lycored-lycopene 2000 mcg.
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Spirulina
• Spirulina is a microalgae with rich natural source of proteins,
carotenoids and other micronutrients.
• The chemopreventive capacity to reverse precancerous lesions
of spirulina is attributed to the antioxidant property with high
amount of beta carotene and superoxide dismutase.
• An intervention study was conducted on 40 oral submucous
fibrosis cases,divided into two groups, group A (spirulina
group) and group B (placebo group). Group A received
spirulina 500 mg twice daily and biweekly intralesional
steroid injection of Betamethasone 4 mg/ml for 3 months and
group B was given placebo capsules twice daily and biweekly
intralesional steroid injection of Betamethasone 4 mg/ml for 3
months.
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s• Clinical improvements in mouth opening was significant in
the post treatment period in both Spirulina and placebo
groups. Both the groups showed statistically significant
reduction in burning sensation. However, when both groups
were compared, mouth opening and burning sensation was
found to be statistically very highly significant in favor of the
spirulina group.
Shetty P, Shenai P, Chatra L, Rao PK. Efficacy of spirulina
as an antioxidant adjuvant to corticosteroid injection in management of
oral submucous fibrosis. Indian J Dent Res 2013;24:347-50
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• In another study,68 subjects with clinico-pathologically
diagnosed OSMF were included in the study They were
divided equally in two groups, Group A (spirulina group) and
Group B (lycopene group). Group A was administered 500
mg spirulina in two divided doses for 3 months, and Group B
was given 8 mg lycopene in two divided doses of 4 mg for 3
months.
• The patients in both the groups showed improvement in all the
parameters measured. Clinical improvements in mouth
opening was significant in Group B ,whereas
ulcers/erosions/vesicles significantly improved in the Group
A.
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The authors concluded that Lycopene can bring about significant
clinical improvements in the symptoms like mouth opening,
while spirulina can significantly improve ulcers/ erosion/
vesicles. Both the drugs also showed improvement in pain
associated with the lesion and burning sensation.
Patil S, Khandelwal S, Maheshwari S. Comparative efficacy of
newer antioxidants spirulina and lycopene for the treatment of oral
submucous fibrosis. Clin Cancer Investig J 2014;3:482-6
Brand names
• Holy-health (cap), herbal hills(cap), jiaze (tablets)
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ALOE VERA
• Aloe vera is a mannoprotein containing many amino acids
known as 'wound healing hormones'.
• The polysaccharides contained in the gel of the leaves,
promote wound healing and have anti-inflammatory,
immunomodulatory, antioxidant, and gastro-protective
properties. Further, sterols in aloe vera have strong ability to
inhibit inflammation similar to the action of cortisone without
any side effects. It can be found easily and is of low cost in
India.
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• 20 study subjects with OSMF were included in the study.
Patients were divided into two groups. There were 10 patients
in each group; group A subjects received 5 mg of aloe vera
gel to be applied topically three times daily for 3 months and
group B subjects received antioxidant capsules twice daily for
3 months.
• The results showed that Aloe vera responded better in all the
parameters assessed and responded in all the
clinicohistopathological stages particularly in those with mild-
stage clinically and early-stage histopathologically. Aloe vera
showed a statistically significant reduction in burning
sensation (P = 0.008), improvement in mouth opening
(P = 0.02), and cheek flexibility (P = 0.01) on comparing with
the antioxidant group.
Sudarshar R et al. Aloe vera in the treatment for oral
submucous fibrosis – a preliminary study J Oral Pathol Med (2012) 41:
755–761
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• In another study 120 clinicopathologically diagnosed OSMF
patients, were included in the study. They were divided
equally into, Group A (lycopene group) and Group B (aloe
vera group). Group A was administered 8mg lycopene in two
divided doses of 4mg daily and Group B was given 5mg aloe
vera gel to be applied topically thrice daily for 3 months.
• The results showed that though, there is no definitive
treatment for the condition; however, lycopene can bring
about significant clinical improvements in the symptoms like
mouth opening and tongue protrusion when compared to aloe
vera. Both the drugs appear to be promising in the treatment
of OSMF.
Patil S, Sghaireen M G, Maheshwari S, Kunsi SR, Sahu
R. Comparative study of the efficacy of lycopene and aloe vera in the
treatment of oral submucous fibrosis. Int J Health Allied Sci 2015;4:13-7
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Turmeric
• Turmeric acts by decreasing the number of micronuclei in the
circulating lymphocytes and by acting as an excellent
scavenger of free radicals.
Taneja L, Nagpal A, Vohra P, Arya V. Oral submucous
fibrosis: An oral physician approach. J Innov Dent 2011;1:14-18
• The anti-inflammatory and antioxidant properties of curcumin
are responsible for its chemopreventive action.
• It has been seen that curcumin lowers the activity of STE
(smokeless tobacco extract)- or NNK (nicotine derived
nitrosamine ketone)-induced NF-κB (nuclear factor kappa-
light-chain-enhancer of activated B cells) and COX-2 in oral
premalignant and cancer cells.
Rai B, Kaur J, Jacobs R, Singh J. Possible action
mechanism for curcumin in pre-cancerous lesions based on serum and
salivary markers of oxidative stress. J Oral Sci 2010;52:251-6
8/6/2016 55
• The anti-inflammatory and antioxidant activities of curcumin
have been observed in in vitro studies that showed the
inhibition of lipo-oxygenase and cyclo-oxygenase (COX)
activities that can induce inflammation.
• Dose –cap 500 mg tid for 3 months.
8/6/2016 56
• One study carried out that includes 30 subjects diagnosed with
OSMF. The patients were administered commercially
available turmeric; their mouth opening and burning sensation
on VAS scale were evaluated at regular intervals, and the data
was then compared. The improvement in mouth opening was
not significant; however, the change in burning sensation on
VAS was significant.
Agarwal N, Singh D, Sinha A, Srivastava S, Prasad RK,
Singh G. Evaluation of efficacy of turmeric in management of oral
submucous fibrosis . J Indian Acad Oral Med Radiol 2014;26:260-3
8/6/2016 57
• Another studied the effect of turmeric oil (600mg), alcohol
extracts of turmeric (3g) and turmeric oleoresin (600mg) on
cytogenetic damage in patients suffering from OSMF after
daily intake for 3 months. They concluded that turmeric oil
and turmeric oleoresin both act synergistically in vitro to offer
protection against DNA damage. Thus, curcumin holds a
promising future in the treatment of OSMF.
Hastak K, Lubri N, Jakhi S.D. Effect of turmeric oil and turmeric
oleoresin on cytogenic damage in patients suffering from oral submucous
fbrosis. Cancer Letters; 116: 265-9,1997.
8/6/2016 58
8/6/2016 59
ALPHA LIPOIC ACID
• Alpha lipoic acid (also called thioctic acid) has been claimed
to be the near-perfect antioxidant.
• Alpha lipoic acid is able to scavenge more free radical cells
than most other antioxidants, the majority of which tend to
dissolve in either fat or water but not both.
• A case-control study was conducted on 18 patients of OSMF
(9 cases and 9 controls). The case group was treated using
alpha lipoic acid in addition to the intralesional steroid and
hyaluronidase injections used in the control group.
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• The results showed that the cases in the alpha lipoic acid
group exhibited better relief of symptoms such as burning
sensation of the mucosa and mouth opening, as compared to
the controls. The use of alpha lipoic acid along with
intralesional steroids and hyaluronidase caused reversal of
higher clinical stages to lower ones.
Rao PK. Efficacy of alpha lipoic acid in adjunct with
intralesional steroids and hyaluronidase in the management of oral
submucous fibrosis. J Can Res Ther 2010;6:508-10
• Alpha-lipoic acid 100 mg, 1 capsule per day for 30 days has shown
reduction in burning sensation and improved mouth opening.
Shetty DN, Shenai P, Chatra L. Oral Submucous Fibrosis:
Review of Modalities of Management. Indian Dentist Research and
Review.2010;66-70
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Acetic acid
• Periodic swabbing of oral mucosa with house hold vinegar
acetic acid at ph 6.5 using a cotton applicator provide
symptomatic relief in some patients.
• It causes swelling of most of the tissues,capable of dissolving
non-cross linked molecules and cross linked collagen fibres
Altered collagen attracting macrophages
Scavanging action promoting collagenolysis.
A.K verma .Volume 4 tobacco counters health.1st ed.2006
8/6/2016 62
Role of physiotherapy
• Kneading is an effective form of massage therapy in
improving the elasticity of fibrous tissues and mobilizing scar
tissues. The gentle soft tissue manipulation is extensively used
in physiotherapy for improving their extensibility.
• The decrease in TMJ mobility is mobilized by forced passive
movements & manipulations to permit more mouth opening.
Vijayakumar M, Priya D. Physiotherapy
for improving mouth opening & tongue protrution in patients with Oral
Submucous Fibrosis (OSMF) – Case Series. International Journal of
Pharmaceutical Science and Health Care. 2013;2(3): 50-58.
8/6/2016 63
Muscle streching exercise
• This may be helpful to prevent further restriction of mouth
movements and to prevent relapse. This can be performed
using mouth gag, acrylic surgical stent, ballooning of mouth,
hot water gargling, inter positioning spatula between the teeth
and adding a new spatula every 5-10 days.
• This is thought to put pressure on fibrous bands.
• It is advocated to use the oral stents over a period of 6 months.
It should be removed only while during meals and at bedtime
otherwise the patient should wear it all day.
Vijayavel. T, Ponni V. management for oral submucous
fibrosis – A comprehensive review. Indian Journal of
Multidisciplinary Dentistry. 2014; 4(1): 869-874.
8/6/2016 64
8/6/2016  65
• A 26-year-old man diagnosed with OSMF (mouth opening at
interincisal level: 34 mm), gave a personal history of a habit
of pan-masala chewing (∼40 g/day) for 2 years. He was
treated with the MED ,followed every month for next 6
months, after which the patient’s mouth opening was improved
to 41 mm.
Patil PG , Patil SP. Novel Mouth-Exercising Device for
Oral Submucous Fibrosis. Journal of Prosthodontics 21 (2012) 556–560
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Heat –Short wave/Micro wave diathermy:
• Heat has been used in the form of lukewarm water, hot rinses
or selective deep heating therapies like short wave or micro
wave diathermy.
• It acts by physiofibrinolysis of bands.
• Microwave diathermy at 2450 MC/s daily for 20 mins at each
site of the lesion with 20 to 25 watts of energy, 15 sittings
were given and reported that the use of microwave diathermy
of great significance for moderately advanced stages but in
very advanced cases results were very poor.
Gupta D, Sharma SC. Oral submucous fibrosis- A new
treatment regimen. Oral Maxillofac Surg. 1988; 46: 830-833.
8/6/2016 67
Medical management
• Interferon gamma
• Placental extracts
• hyaluronidase
• Corticosteroids
• Peripheral Vasodilators
• Immunised milk
• Combination regimen
8/6/2016 68
Interferon-gamma (anti-fibrotic cytokine).
• Decreases fibrosis(down regulates fibroblast proliferation and
collagen synthesis)
• Arrest progession of OSMF
• Increase mouth opening
15 injections of 50 microgram (0.25 ml ) intralesionally twice a
week over 8 weeks
Haque et al.Interferon gamma (IFN-gamma) may reverse oral
submucous fibrosis. J Oral Pathol Med. 2001;30(1):12-21.
8/6/2016 69
In one study investigation is carried out to find
• a) the effect of IFN-γ on collagen synthesis by arecoline-
stimulated OSF fibroblasts in vitro (n=5),
• b) the effect of intra-lesional IFN-γ on the fibrosis of OSF
patients (n=29) and
• c) the immunohistochemical analysis of pre- and post-
treatment inflammatory cell infiltrates and cytokine levels in
the lesional tissue (n=29).
• The results showed that the increased collagen synthesis in
vitro in response to arecoline was inhibited in the presence of
IFN-γ (0.01–10.0 U/ml) in a dose-related way.
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321`a1236y8i85t5tr5• Also this study showed intra-lesional IFN-γ treatment showed
improvement in the patients mouth opening from an inter-
incisal distance before treatment of 21±7 mm, to 30±7 mm
immediately after treatment and 30±8 mm 6-months later,
giving a net gain of 8±4 mm (42%) (range 4–15 mm). Patients
also reported reduced burning dysaesthesia and increased.
Haque et al.Interferon gamma (IFN-gamma) may
reverse oral submucous fibrosis. J Oral Pathol Med. 2001;30(1):12-21.
8/6/2016 71
Placental extract(placentrex)
• Placental extract contains growth factors and anti-
inflammatory agents and it has shown to have anti-
inflammatory and anti-platelet activity.
• It is an aqueous extract of human placenta that contains
nucleotides, enzymes, vitamins, aminoacids & steroids. It acts
by “Biogenic stimulation” which
 Acclerates cellular metabolism through pituitary adreno
cortical axis.
 Assist in the absorption of exudates,stimulates the
regeneration process.
 Increase the physiological action of organs.
 Increase blood circulation by increasing tissue vascularity.
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Its use is based on the method of “tissue therapy” introduced by
Filatov in 1933. No contraindications & the results are found
to be lasting.
Available in 4 forms
 Aqueous solution of human placenta
 Lipoid extracts
 Immuno-gamma globulins
 Tissue coagulants
8/6/2016 73
• The authors presented a case report of 12-year-old girl with
interincisal distance of maximal mouth opening was 1.7 cm.
she was advised to stop chewing areca nuts. Submucous
(intralesional) injection of aqueous extract of healthy human
placenta (Placentrex, 2 ml) was given for two months to the
regions with palpable fibrotic bands.
• The procedure was repeated at an interval of three days. Each
time, 2 ml of solution was deposited around the specific
region on both sides. There was a remarkable improvement in
the burning sensation of the mouth and moderate
improvement in mouth opening.
Anil S,Beena MT. Oral submucous fibrosis in a 12-year-
old girl: case report. Pediatric Dentistry; 1993 -16(2).120-22
8/6/2016 74
• In another study 15 patients with clinico-pathologically
diagnosed OSMF were included in the study. Patients were
divided randomly into three groups and betamethasone,
placental extract & hyaluronidase intralesional injection was
given to the separate groups of the patient for a period of 8
weeks.
• Mouth opening and burning sensation was recorded clinically
& subjective lymprovement in mouth opening was observed
the maximum with intra lesional injection of hyaluronidase
with 9.38mm in average,followed by placentrex and
improvement in burning sensation was observed maximum
with intra lesional injection of betamethasone.
Gupta J.et al.Effiacy of betamethasone, placental extract
and hyaluronidase in the treatment of osmf: a comparative study. E-
Journal of Dentistry;Jan2012, Vol. 2 Issue 1, p132
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• Another study comprise 10 subjects with oral submucous
fibrosis who presented with mouth opening less than 20 mm
were enrolled in the present prospective randomized
controlled trial to assess the effects of placental extract on the
fibrotomy wound covered with a pedicled buccal pad fat (5
patients allocated to the study group, group S and 5 to the
control group, group C)
• The results showed that the average difference in the
preoperative and 4TH week postoperative mouth opening for
group C was 13.8 ± 2.68 mm and was 21.20 ± 2.77 mm in
group S. The median calculated for group C was a 15-mm
increase in mouth opening and was 20 mm in group S.
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• The results obtained with topical application of placental
extract on fibrotomy wound healing and postoperative mouth
opening were superior to those of the control group in whom
placental extract was not used.
Thakur.G et al.Does Topical Application of Placental Extract
Gel on Postoperative Fibrotomy Wound Improve Mouth Opening and
Wound Healing in Patients With Oral Submucous Fibrosis? J.oral
max.surg.july.2015. 1439.e1–1439.e10
8/6/2016 Template copyright 2005 www.brainybetty.com 77
• In combination therapy ,a 33-year-old male patient with
OSMF was given triamcinolone 1 ml (10 mg/ml) +
hyaluronidase 1500 IU + placentrex 2 ml] given in fragmented
doses. After a period of 2 months, the patient had noticed
improvement in the burning sensation of mouth with a feeling
of well-being. His interincisal opening had increased
significantly.
Bhushan KI,Sethi AK.A rare ocular complication following
treatment of oral submucous fibrosis with steroids.Natl J Maxillofac Surg.
2011 Jan-Jun; 2(1): 93–95.
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Placentrix -2cc biweekly for 10 weeks in combination with
dexamethasone and hyaluronidase.
Gupta D, Sharma SC. Oral submucous
fibrosis--a new treatment regimen. J Oral Maxillofac Surg.
1988;46:830–3.
2cc of placentrix injection intralesionally at weekly intervals for
10 weeks was found to be superior to cortisone. In resistant
cases, surgical excision of fibrotic bands with submucosal
placement of fresh human placental grafts was found to be
successful.
Shetty DN, Shenai P, Chatra L. Oral Submucous Fibrosis: Review
of Modalities of Management. Indian Dentist Research and
Review.2010;66-70.
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Hyalouronidase
Reduces burning sensation & trismus.
Acts by breaking down hyaluronic acid, lowers the viscosity of
intracellular substances.
Decreases collagen formation.
“The combination of steroids & hyaluronidase shows better
long-term results than either agent used alone.” (Kakar, 1985)
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• It is recommended that triamcinolone acetonide (10 mg/ml)
combined with 1500 IU of hyaluronidase should be given
intralesionally particularly in retromolar trigone area half dose
each side at 15 days interval for a total of 11 injections in 22
wk.
Singh et al.Efficacy of hydrocortisone acetate/hyaluronidase vs
triamcinolone acetonide/hyaluronidase in the treatment of oral submucous
fibrosis Indian J Med Res 131, May 2010, pp 665-669
• A total of 28 patients treated by administering an intralesional
injection of dexamethasone1.5 ml, hyaluronidase 1500 IU with
0.5 ml lignocaine HCL injected intralesionally biweekly for 4
weeks. Improvement in the patient’s mouth opening with a net
gain of 6 ± 2 mm (92%), the range being 4-8 mm. Defi nite
reduction in burning sensation, painful ulceration and
blanching of oral mucosa and patient followed up for an
average of 9 months.
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• The authors concluded that the injection of hyaluronidase with
dexamethasone is an eff ective method of managing Grade III
OSMF and can possibly eliminate the morbidity associated
with surgical management.
James L. et al.Management of Oral Submucous
Fibrosis with Injection of Hyaluronidase and Dexamethasone in Grade III
Oral Submucous Fibrosis: A Retrospective Study. Journal of International
Oral Health 2015; 7(8):1-4
8/6/2016 82
• In combination therapy 100 patients with OSMF were
randomly divided into two groups. Group A patients received
combination of hydrocortisone acetate (1.5 ml)/hyaluronidase
(1500 IU) at weekly interval submucosally in
pterygomandibular raphe, half dose on each side for 22 wk.
Group B patients received combination of triamcinolone
acetonide (10 mg/ml)/ hyaluronidase (1500 IU) at 15 days
interval for 22 wk.
• Treatment outcome was evaluated on the basis of
improvement in symptom score, sign score and
histopathological improvement. Treatment regimen of group
B was more convenient to the patients because less number of
visits required and cheap. No side effects were seen. A follow
up study is required to see long term effects.
• Singh M.et al. Efficacy of hydrocortisone
acetate/hyaluronidase vs triamcinolone acetonide/hyaluronidase in the
treatment of oral submucous fibrosis. Indian J Med Res 131, May 2010, pp
665-669
8/6/2016 83
Brand names
• Facidase 1500 IU X 2 ml.
• Hylorase 1500 IU
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Intra-lesional steroids
• Steroids also prevent or suppress inflammatory reactions
thereby preventing fibrosis by decreasing fibroblastic
proliferation and deposition of collagen.
• The initial symptomatic relief could be due to the anti-
inflammatory action of the steroids, which helps in clearing
the juxtaepithelial inflammatory reaction.
Elluru Venkatesh et al .Archives of Dental Sciences Role
of Corticosteroids in Dentistry 2010,Vol.1,Issue1, 03-11
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• Inhibit pg synthesis
• Anti-inflammatory
• Inhibit DNA synthesis of fibro-epithelial cells
• Inhibit collagen synthesis.
Ponec M et al. Effects of glucocorticosteroids on primary human skin
fibroblasts. Archives of dermatological research.1977; 259,(2), 125-134
• Steroids exhibit dose dependent enhancement in the
proportion of phagocytic cells which phagocytose collagen
and fibronectin
Tsai CC, Ma RH, Shieh TY. Deficiency in collagen and
fibronectin phagocytosis by human buccal mucosa fibroblasts in vitro as a
possible mechanism for oral submucous fibrosis. J Oral Pathol
Med 1999; 28: 59-63
8/6/2016 86
• Submucosal injections of a combination of dexamethasone (4
mg/l0ml) and 2 parts of hyaluronidase (200 u.s.p unit/ml)
diluted in 1 ml of 2 % xylocaine by means of a 27 gauge
dental needle, not more than 0.2 ml solution/site for a period
of 20 weeks.
• Similarly submucosal injection of triamcinolone 10 mg /ml
diluted in 1 ml of lidocaine 2 % to avoid immediate tissue
irritation and to facilitate proper distribution of drug to al the
sites biweekly can be used.
• Borle R M, Borle S R, Management of oral
submucous fibrosis-A conservative approach. JOMS 1991; 49:788-91.
8/6/2016 87
8/6/2016 Template copyright 2005 www.brainybetty.com 88
• A total of 28 patients diagnosed with OSMF were treated in
for a time period of 9 months by administering an
intralesional injection of dexamethasone1.5 ml, hyaluronidase
1500 IU with 0.5 ml lignocaine HCL injected intralesionally
biweekly for 4 weeks.
• Results showed there is Improvement in the patient’s mouth
opening with a net gain of 6 ± 2 mm (92%), the range being 4-
8 mm. Definite reduction in burning sensation, painful
ulceration and blanching of oral mucosa and patient followed
up for an average of 9 months. The authors concluded that
Injection of hyaluronidase with dexamethasone is an effective
method of managing Grade III OSMF and can possibly
eliminate the morbidity associated with surgical management.
• James L et al.Management of Oral Submucous
Fibrosis with Injection of Hyaluronidase and Dexamethasone in Grade III
Oral Submucous Fibrosis: A Retrospective Study.j int oral
health.20157(8):1-4
8/6/2016 89
• IMMUNE MILK- Immune milk is a kind of skimmed milk
produced from cows immunised with multiple human
intestinal bacteria.
• It has good anti-inflammatory effect & contains moderate
amounts of Vit. A, C, B1, B2, B6, B12, nicotinic acid,
pantothenic acid, folic acid, iron, copper & zinc.
• Though chemically its identical to commercial milk but it
contains 20-30% higher concentration of IgG type 1 antibody.
• 45gms of immunised milk powder twice a day, for 3 months
showed significant improvement in symptoms of OSMF.
Tai YS.et al 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. J Oral Pathol Med.2001
Nov;30(10):618-25.
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• In this preliminary study, 26 OSMF 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 OSMF patients who
received only oral habit intervention served as the control
group. Interincisor distance was significantly improved (> or
=3 mm of the baseline measurement) in 18 of the 26 (69.2%)
OSMF patients in the experimental group at exit. However, in
the control group ,none of the OSMF patients had an increase
in interincisor distance greater than 2 mm.
The authors concluded that oral administration of immune milk
leads to significant improvements of symptoms and signs in
OSF patients.
Tai YS.et al 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. J Oral
Pathol Med. 2001 Nov;30(10):618-25.
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Immuno-modulatory drugs
Antigen
Sensitized lymphocytes
Inflammatory reaction
Fibroblast proliferation
Increased collagen synthesis
8/6/2016 92
Immuno-
modulators
Levamisole
Immuno-modulatory drug, given at a dose of 50 mg tab (TID)
showed significant improvement in signs and symptoms. It
modifies both cellular and humoral immunity, has an Anti-
inflammatory effects and its ability to modulate inflammatory
cytokines reduces burning sensation.
Jirge V, Shashikanth MC, Ali IM, Nisheeth A.
Levamisole and antioxidants in the management of oral submucous
fibrosis: A comparative study. J Indian Acad Oral Med
Radiol. 2008;20:135–40.
Balaji rao et al.1993 levamisole 150 mg-once daily for 3 days in
a week for 6-8 weeks
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Peripheral vasodialator
Pentoxifylline (Trental)
• It has anti inflammatory properties like altering fibroblast
physiology, suppressing leucocyte function and stimulating
fibrinolysis.
• Its immuno-modulating actions include neutrophil
degranulation, increasing leukocyte adhesion, promotes
natural killer cell activity, release of peroxides, production of
tumor necrosis factor and inhibits T and B cell activation.
• Pentoxifylline 400 mg three times daily, as coated, sustained
release tablets have been used as an adjunct therapy resulted
in improvement in mouth opening, tongue protrusion, and
relief from perioral fibrotic bands.
• Shetty DN, Shenai P, Chatra L. Oral Submucous
Fibrosis: Review of Modalities of Management. Indian Dentist Research
and Review.2010;66-70
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Nylindrin hydrochloride
 Sharma JK et al.1987 recommended the use of nylindrin
hydrochloride which is a peripheral vasodialator that reduces
ischaemia.
 Used in combination therapy.
nylindrin hydrochloride+vit A,E,B complex+placental
extract+steroids+physiotherapy
8/6/2016 95
Lasers
• The ErCr:YSGG (waterlase C-100) laser was used to release
the fibrotic bands of OSMF that were causing limited mouth
opening.
• It works on "hydro-photonic process" in which the laser
energy from the ErCr:YSGG is able to interact with water
droplets at tissue to create water molecule excitation. This, in
turn, causes water droplet micro-expansion and propulsion
that gives clean and precise hard-tissue cut.
• Analgesics,anti-inflammatory and muscle –relaxing effect.
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ULTRASOUND.
• During ultrasound therapy, cell membrane permeability is
increased by altering sodium and potassium ion gradients.
This increased permeability improves gas exchange and
promotes healing.
• It increases vasodilatation.
• accelerates lymph flow
• decreases inflammation and stimulates metabolism.
• Ultrasound used for therapeutic purpose has a frequency of
about 0.8-1 MHz and an intensity of 0.5-3 w/cm2.
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• Ultrasound treatment accelerate healing, increase the
extensibility of collagen fibers, provide pain relief and
selectively raises the temperature in some well circumscribed
areas.
• Ultrasound of dose ranging from 0.6 to 2.0 W/Cm2 pulsed 1:1
or 1:2 ( 50% or 33.3 % duty cycle), Frequency of 3 MHz, 5cm
diameter transducer head for 3 to 4 minutes to each side over
the cheek for 15 consecutive days with permissible one day
off each week.
Vijayakumar M, Priya D. Physiotherapy for improving
mouth opening & tongue protrution in patients with Oral Submucous
Fibrosis (OSMF) – Case Series. International Journal of Pharmaceutical
Science and Health Care. 2013;2(3): 50-58.
8/6/2016 98
Surgical treatment
• Motawetz G.1987.-Excision of fibrotic bands with sub-
mucosal placements of human skin grafts.
• Gupta and sharma et al 1988. Excision of fibrotic bands with
sub-mucosal placements of human placental grafts.
• Khanna and Andrade 1996-in advanced cases bilateral
temporal myotomy,bilateral coronoidectomy and palatal
island flap.
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Grading and treatment modalities Gupta DCS et al.
• Grade I-Only blanching of oral mucosa without symptoms.
• Grade II-Burning sensations ; Dryness of mouth ;vesicles /
ulcers in the mouth without tongue involvement.
• Grade III- In addition to grade II restriction of mouth
opening .
• Grade IV- In addition to grade III palpable bands all over the
mouth without tongue involvement Grade V and tongue
involvement .
• GradeVI-Oral submucous fibrosis along withhistologicaly
proven oral cancer.
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GROUP I : : Removal of etiological factors Discontinuation of
habits ( paan, beetel nut, tobacco chewing and intake of spicy
food ) Nutritional Therapy : Multivitamin therapy and Iron
therapy to boost up the nutritional status of the patients.
GROUP II : Topical Therapy patient's in grade I & II and to
prevent relapse after other treatment modalities.
• Triamcinolone acetate 0.1 % with neomycin - to be applied to
the oral mucosa three times daily and the patients were
advised to let the saliva drool for 15 minutes.
• This one month course was repeated after two months.
Pappain and urea mixture : to be applied intra orally 2-3 times
daily for 15 days and to be repeated after one month
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• Papain mixture : The mode of action of papain mixture is by
biogenic stimulation and the proteolytic action.
• UREA : keratolytic agent, induces surface lysis of keratin
layer of oral mucosa and early absorption at the lesional site ,
breaking the fibro peptide linkages of the fibrous layer,
leading to slight laxity of the oral mucous membrane stiffness
• GROUP III -Injectable therapy : For patients in grade III, IV,
V Injectable Hyaluronidase 1500 I.U, 0.5 ml injected intra
lesionally twice a week for 10 weeks.
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• Dexamethasone 1.5 ml with 0.5 ml of lignocaine HCL intra
lesionally biweekly for 5 weeks.
• Placental extracts (PLACENTRIX) -2 ml intra lesionally once
a week for 4 weeks ; along with injection ranidone ( Iodine &
vit B complex ) I.M
• HYALURONIDASE causes collagen destruction as collagen
of OSMF patients ( as compared to controls) is attacked
rapidly by Hyaluronidase. Also it breaks down Hyaluronic
acid and causes lowered viscosity of intercellular cementing
substance
8/6/2016 103
• STEROIDS -functions as immune suppressive agents by
opposing the action of the soluble factors released by the
sensitized lymphocytes following activation by non specific
antigens. Also suppresses the inflammatory reaction. Thus
fibrosis is prevented by a decrease in fibroblastic proliferation
and deposition of collagen.
• Placentrix : Acts by biogenic stimulation.
• Ranidone , an iodine and vit B complex preparation stimulates
the metabolic processes in the body.
• Vit B complex potentiates the action of Iodine and makes it
non toxic.
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GROUP IV-Micro wave Diathermy using " microtone 200 "
unit producing microwaves of 2450 MC / S : for patients in
grade IV & V
• One sitting of 20 min a day for 15 days to give an energy of
20 watts .
• Microwave Diathermy causes physio fibrolysis of bands.
8/6/2016 105
GROUP V : Surgical treatment for patients with grade IV & V
or with isolated bands in retromolar region and in patients in
grade VI
• Forceful mouth opening : Patients with severe trismus and
having unerupted / partially erupted 3rd molars had their
mouth forcefully opened, and the patients were asked to apply
Kamillosan ointment to reduce scar formation and promote
healing. Topical steroids are used to prevent relapse.
• Rotated tongue flap or skin grafting- for patients with Isolated
bands in retromolar region and trismus .
• Gupta Dinesh Chandra S, Dolas Rameshwar S, Ali Iqbal.
Treatment of Oral submucous fibrosis : How they stand today? A Study of
600 cases. Ind J of Oral and Maxillo surg 1992(7);43.
•
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KoneruA et al.A systematic review of various treatment modalities for oral
submucous fibrosis Journal of Advanced Clinical & Research Insights (2014), 2,
64–72
References
 Greenberg MS, Glick M, Ship JA. Burket’s Oral
Medicine.11th edition.Ontario:BC Decker Inc;2003.p. 88-89
 Shafer’s textbook of oral pathology-6th ed
 Neville oral pathology
 Rajlalitha P.Vali . S.Molecular pathogenesis of oral
submucous fibrosis – a collagen metabolic disorder. J Oral
Pathol Med (2005) 34: 321–8
 Sanadi et al. lycopene: it’s role in health and disease , IJPSR,
2012; Vol. 3(12): 4578-4582
 . Murti PR, Bhonsle RB, Gupta PC , Daftari DK, Pindborg JJ,
Mehta FS. Etiology of oral submucous fibrosis with special
reference to role of arecanut chewing. J. Oral Pathol Med.
1995; 24: 145-52.
8/6/2016 108
• Gupta Dinesh Chandra S, Dolas Rameshwar S, Ali Iqbal.
Treatment of Oral submucous fibrosis : How they stand
today? A Study of 600 cases. Ind J of Oral and Maxillo surg
1992(7);43.
• Singh et al.Efficacy of hydrocortisone acetate/hyaluronidase
vs triamcinolone acetonide/hyaluronidase in the treatment of
oral submucous fibrosis Indian J Med Res 131, May 2010, pp
665-669
 Phatak A. Fibrin producing factor in Oral Submucous
Fibrosis. Indian Journal of Otolaryngology and Head & Neck
Surgery 1979; 31(4):103-4.
 Rajendran R, Sugathan C, Remani P, Ankathil R,
Vijayakumar T. Cell mediated and humoral immune
responses in oral submucous fibrosis.
Cancer1986;58(12):2628-31.
8/6/2016 109
• Tilakratne WM, Klini Kowski NF, Saku T, Peters TJ,
Warnakulasuriya S: Oral submucous fibrosis: Review on
etiology and pathogenesis. Oral oncol 2005: 30: 30-32.
8/6/2016 110
8/6/2016 Template copyright 2005 www.brainybetty.com 111
8/6/2016 Template copyright 2005 www.brainybetty.com 112

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management of oral submucous fibrosis

  • 1. MANAGEMENT OF ORAL SUBMUCOUS FIBROSIS PRESENTED BY DR.PANKAJ GUPTA PG STUDENT DEPT.OF OMDR
  • 2. CONTENTS  Introduction  Prevalance ,age ,gender  Etiopathogenesis  Classification  Clinical features  Management  References 8/6/2016 2
  • 3. Introduction • Oral submucous fibrosis is defined as “An insidious chronic disease affecting any part of the oral cavity and sometimes the pharynx. It is always associated with juxta-epithelial inflammatory reaction followed by fibroelastic changes of the lamina propria with epithelial atrophy leading to stiffness of the oral mucosa and causing trismus and inability to speak”. Pindborg and Sirsat in 1966. • The disease is exclusively reported in Indian population and in South East Asia, but the cases have been reported worldwide like Kenya, China, UK, Saudi Arabia and other parts of the world where Asians have migrated and are migrating. 8/6/2016 3
  • 4. 8/6/2016 4 • It has been linked with an increased risk of malignancy. • A wide range of treatment including drug therapy, surgical therapy, and physiotherapy have been attempted till date, with varying degrees of benefit, but none have been able to cure this disease. • The treatment depends on the level of clinical involvement. At a very early stage, cessation of the habit is adequate. Medical/surgical treatment is necessary for moderate to severe cases. Surgical treatment is the method of choice in patients with marked limitation of mouth opening or in patients not responding to the conservative management.
  • 5. Prevalence • Worldwide, estimates of OSMF shows a confinement to Indians and Southeast Asians with 0.2-1.2% of an urban population attending dental clinics are affected by OSMF. • Ali FM, Aher V, Prasant M C et al. Oral submucous fibrosis: Comparing clinical grading with duration and frequency of habit among areca nut and its products chewers. J Can Res Ther 2013;9:471-6. • The age range of patients with OSMF is wide,most common between 20 and 40 years of age. • Age group below 20 years of age more often contract OSMF. Rajendran R, Sugathan C, Remani P, Ankathil R, Vijayakumar T. Cell mediated and humoral immune responses in oral submucous fibrosis. Cancer.1986;58(12):2628-31. Greenberg MS, Glick M, Ship JA. Burket’s Oral Medicine.11th edition.Ontario:BC Decker Inc;2003.p. 88-89 8/6/2016 5
  • 6. Gender The prevalence in indian population is 5% for women and 2 % for men. Greenberg MS, Glick M, Ship JA. Burket’s Oral Medicine.11th edition.Ontario:BC Decker Inc;2003.p. 88-89 Malignant transformation • Malignant transformation rate of OSMF was found to be in the range of 7-13% and incidence over a 10 year period is 8%. Greenberg MS, Glick M, Ship JA. Burket’s Oral Medicine.11th edition.Ontario:BC Decker Inc;2003.p. 88-89 • According to long-term follow-up studies, a transformation rate of 7.6% over a period of 17 years was reported. Tilakaratne WM, Klinikowski MF, Saku T, Peters TJ, Warnakulasuriya S. Oral submucous fibrosis: Review on etiology and pathogenesis. Oral Oncol.2006;42:561-8 8/6/2016 6
  • 7. Etio-pathogenesis  Areca nut/betel nut  Tobacco and lime  Nutritional deficiencies  Immunological disorders  Collagen disorders  Capsasin(a prime component in chillies) 8/6/2016 7
  • 9. Immunological disorders Increased levels of serum IgA Hyperglobulinaemia, imbalance in immuno-regulation and alteration in local tissue architecture. R.Rajendran. Oral submucous fibrosis: etiology, pathogenesis, and future research. Bulletin of the WHO. 1994; 72(6): 985-996. 8/6/2016 9
  • 10. Collagen disorder Increased collagen production 1)Activation of procollagen genes 2)Elevation of pro-collagen proteinase levels 3) Up-regulation of lysyl –oxidase(LOX) activity 8/6/2016 10
  • 11. Classification According to Pindborg in 1989 OSMF is clinically divided into 3 stages, and the physical findings vary accordingly, reported by Murti, in 1992; Cox in 1996; Aziz in 1997 Stage 1: Stomatitis includes erythematous mucosa  Vesicles and mucosal ulcers  Melanotic mucosal pigmentation  Mucosal petechia. 8/6/2016 11
  • 12. Stage 2: Fibrosis occurs in ruptured vesicles and ulcers when they heal, which is the hallmark of this stage.  Early lesions demonstrate blanching of the oral mucosa.  Older lesions include vertical and circular palpable fibrous bands in the buccal mucosa and around the mouth opening or lips, resulting in a mottled, marble like appearance of the mucosa because of the vertical, thick, fibrous bands running in a blanching mucosa. 8/6/2016 12
  • 13. • Reduction of the mouth opening • Stiff and small tongue. • Blanched and leathery floor of the mouth. • Fibrotic and depigmented gingiva. • Rubbery soft palate with decreased mobility. • Blanched and atrophic tonsils. • Shrunken bud like uvula. • Sinking of the cheeks, not commensurate with age or nutritional status Stage 3: Squealae of OSMF are as follows: • Leukoplakia is precancerous and is found in more than 25% of individuals with OSMF. • Speech and hearing deficits may occur because of involvement of the tongue and the eustachian tubes. 8/6/2016 13
  • 14. Khanna and Andrade in 1995 developed a group classification system for the surgical management of trismus • Group I: Earliest stage without mouth opening limitations with an interincisal distance of greater than 35 mm. • Group II: Patients with an inter-incisal distance of 26-35 mm. • Group III: Moderately advanced cases with an interincisal distance of 15-26 mm. Fibrotic bands are visible at the soft palate, and pterygomandibular raphe and anterior pillars of fauces. • Group IVA: Trismus is severe, with an interincisal distance of less than 15 mm and extensive fibrosis of all the oral mucosa. • Group IVB: Disease is most advanced, with premalignant and malignant changes throughout the mucosa. 8/6/2016 14
  • 15. Clinical features  Blanching, i.e., marble-like appearance of the oral mucosa and stiffness of the oral mucosa.  Trismus  Burning sensation in the mouth when consuming spicy food.  Intolerance to eating hot and spicy foods.  Appearance of blisters especially on the palate, ulcerations. or recurrent generalized inflammation of the oral mucosa.  Reduced mobility of the soft palate and tongue  Defective gustatory sensation and dryness of the mouth. 15
  • 16. 8/6/2016 16 Clinical picture showing: A. Marble-like appearance of soft palate, faucial pillars & upper pharyngeal mucosa B. shrunken uvula, blanching of left buccal mucosa & retromolar region C. Fibrosis & depapillation of tongue. D. Blanching of right buccal mucosa E. Fibrosis & pigmentation of lower lip
  • 17. Management of OSMF • Preventive measures - Discontinuation of Habit and Counselling • Nutritional support • Physio-therapy: Kneading Muscle stretching exercises Heat –Short wave/Micro wave diathermy • Medical management • Ultrasound and laser therapy • Surgical therapy 8/6/2016 17
  • 18. Preventive measures - Discontinuation of Habit and Counseling  The preventive measure should be in the form of stoppage of the habit of areca nut chewing.  Patients should be explained about the condition and its probable malignant potential and counselling should be given for de-addiction. 8/6/2016 18
  • 19. Role of Areca nut in OSMF • The alkaloids and flavonoids from the areca nut are absorbed and undergoes metabolism. These alkaloids undergo nitrosation and give rise to nitrosamines, which might have a cytotoxic effect on cells. • Additionally, these constituents of areca nut and their metabolites are a source of constant irritation to oral tissues. • Furthermore, the micro trauma produced by the friction of rough of areca nut fragments also facilitates the diffusion of alkaloids and flavonoids into the subepithelial connective tissue, resulting in juxtaepithelial inflammatory cell infiltration. . Chiang CP, Hsieh RP, Chen TH et al. High incidence of autoantibodies in Taiwanese patients with oral submucous fibrosis. J Oral Pathol Med 2002; 31: 402–9. 8/6/2016 19
  • 20. Oral mucosa Betel quid Constant irritation Chronic inflammation Activated T cell and macrophages at the site Increase in cytokines IL 6, TNF, Ifa, increase in growth factor TGF-β 8/6/2016 20
  • 21. • The two main pathways regulated by TGF-β are collagen production pathway and collagen degradation pathway, along with the chemical constituents present in areca nut. Increased collagen production 1)Activation of procollagen genes 2)Elevation of pro-collagen proteinase levels 3) Up-regulation of lysyl –oxidase(LOX) activity 8/6/2016 21
  • 24. 8/6/2016 24 Rajlalitha PV . S.Molecular pathogenesis of oral submucous fibrosis – A collagen metabolic disorder. J Oral Pathol Med .2005 ;34: 321–8
  • 25. • Studies have supported that by showing that early discontinuation of the habit will result in improved clinical outcomes. • A study carried out on 27600 individuals in ernakulam,kerala aged 15 years and above. OSMF was diagnosed and biopsied was performed.Follow up was done annually to determine malignant transformation rates and natural history of the disease.The results showed that after 17 years,Cancer developed in 5 patients,all of them had the habit of chewing tobacco and areca nut with betel leaves and lime. Murti PR et al. Malignant transformation rate in oral submucous fibrosis over a 17-year period. Community Dent Oral Epidemiol. 1985 Dec;13(6):340-1 8/6/2016 25
  • 26. • A dose-dependent relationship was observed for both frequency and duration of chewing areca nut in the development of OSMF. • In a study ,highest incidence of OSMF with increasing severity was associated with those who chew areca nut more than 10/ day for more than 5-10 min. Tilakaratne WM, Klinikowski MF, Saku T, Peters TJ, Warnakulasuriya S. Oral submucous fibrosis: Review on aetiology and pathogenesis. Oral Oncol. 2006;42:561–8 • The severity and the time taken for the development of the disease may also vary according to the preparation of areca nut consumed. Ali FM, Aher V, Prasant MC, Bhushan P, Mudhol A, Suryavanshi H. Oral submucous fibrosis: Comparing clinical grading with duration and frequency of habit among areca nut and its products chewers. J Cancer Res Ther. 2013;9:471–6 8/6/2016 26
  • 27.  Stoppage of areca nut chewing is foremost important measure to treat OSMF. Nicotine Replacement Therapy • Supplied as a gum, skin patch, nasal spray, or inhaler. It works by providing a substitute source of nicotine, without the other harmful components of tobacco. • Nicotine medications make it easier to abstain from tobacco by replacing, at least partially, the nicotine formerly obtained from tobacco and thereby providing nicotine-mediated neuropharmacologic effects. 8/6/2016 27
  • 28. There appear to be at least three major mechanisms of action by which NRT medications support tobacco cessation efforts. • Reduce either general withdrawal symptoms or at least prominent ones. • Reduce the reinforcing effects of tobacco-delivered nicotine. • Finally, nicotine medications may provide some effects for such as sustaining desirable mood and attention states, making it easier to handle stressful or boring situations, and managing hunger and body weight gain. 8/6/2016 28
  • 29. • Zyban (bupropion hydrochloride) and Chantix (varenicline) are non-nicotine-containing medications available by prescription. • Zyban reduces the symptoms of nicotine withdrawal by acting on chemicals in the brain related to nicotine cravings. Zyban is also prescribed under another name “Wellbutrin” to treat depression. • Chantix lessens pleasure from smoking and reduces symptoms of withdrawal. Available in 2mg ,4mg dose. 8/6/2016 29
  • 30. Role of chillies • The role of chillies (Capsicum annum and Capsicum frutescence) ingestion in the pathogenesis of OSMF is controversial. Sirsat in 1960 done a study demonstrated that the capsaicin in chilies stimulates widespread palatal fibrosis in rats. • According to Pillai in 1992 the incidence of OSMF is lower in Mexico and South America than in India, despite the higher dietary intake of chilies. • Pillai R, Balaram P, Reddiar KS. Pathogenesis of oral submucous fibrosis. Relationship to risk factors associated with oral cancer. Cancer. Apr 15 1992;69(8):2011-20. • A hypersensitivity reaction to chilies is believed to contribute to OSMF. Aziz SR.Oral submucous fibrosis: an unusual disease. J N J Dent Assoc.1997. 68: 17–19 . 8/6/2016 30
  • 31. • Chilies are thought to irritate the oral mucosa and cause an inflammatory reaction and along with continued use of chilies and other spices, continued irritation of the mucosa causes chronic inflammation which leads to fibrosis formation. Ahmad MS. Epidemiological and etiological study of oral submucous fibrosis among Gutkha chewers of Patna, Bihar, India. J Indian Soc Pedod Prev Dent.2006;84-89. • Capsaicin, which is vanillylamide of 8-methyl- 6-nonenic acid, is the active ingredient of chillies, play an etiological role in oral submucous fibrosis. R.Rajendran. Oral submucous fibrosis: etiology, pathogenesis, and future research. Bulletin of the WHO. 1994; 72(6): 985- 996. 8/6/2016 31
  • 32. • It may be mentioned that chillies can damage the cells of the mucosa and if this is continuous, it probably causes chronic inflammation, which leads to the formation of excessive fibrosis. • So chillies have indirect effect on the pathogenesis of OSMF as hypersensitivity to chillies is often explained as a common factor in the development of OSMF. Rajendran R. Oral submucous fibrosis: Etiology, pathogenesis and future research. Bull WHO 1994;72:985-9 8/6/2016 32
  • 33. Nutritional support • Malnutrition is a major problem for the inhabitants of most countries where OSMF is prevalent. • Deficiencies of vitamins and iron have been implicated as being of etiological importance in OSMF. • The rationale of giving nutrients in OSMF patients is to correct deficiency states and promote normal cellular processes present in health that help to protect against adverse events including carcinogenesis. Gupta DCS, Rameshwar D, Iqbal A .Treatment modalities in oral submucous fibrosis: how they stand today? Study of 600 cases.1992 .Indian J Oral Maxillofac Surg: 43–47. 8/6/2016 33
  • 34. • Supplementing the diet with foods rich in vitamins A, B complex, and C and iron • Advice green leafy vegetables, red tomatoes, fresh fruits. • Advice Green tea • High protein diet. Beneficial effects of Vitamin A • Vitamin A plays a major role in the epithelial differentiation, in mucous secretary and keratinisation tissues and as well as in adequate concentration it delays, slows, arrests or even reverse the progress of premalignant cells to cells with invasive malignant potential. 8/6/2016 34
  • 35. Beta carotene • In one study, an attempt was made to analyze serum levels of beta carotene in 45 patients with oral submucous fibrosis and 45 age- and sex-matched controls.The serum beta carotene level was significantly lower in the patients with OSMF than in the controls. • When the values were compared between different disease stages, the maximum reduction of beta carotene was evident for Grade III OSMF, as compared with Grade I and II .The results of the study showed that beta carotene plays an important role in the pathogenesis of OSMF, and that its level decreases with disease progression. OSMF patients should be treated with a diet rich in beta carotene to reduce disease severity and progression towards malignancy. Aggarwal A, Shetti A Keluskar V. Bagewadi A.Estimation of serum beta carotene levels in patients with oral submucous fibrosis in India. J Oral Sci. 2011 Dec;53(4):427-31. 8/6/2016 35
  • 36.  Prevent the oxidation of essential cellular constituents such as formation of oxidation products.  Act as scavenger for free radicals.  Increase the number of circulating lymphocytes.  Enhance the proliferation and induction of cytotoxic t-cells.  Increase the no. of helper t-cells and TNF. Brand names- vitamin A(50000 IU) • VA(50000 IU) 8/6/2016 36
  • 37. • Study by Maher et al. evaluated the efficacy of combination of micronutrients (vitamins A, B complex, C, D, and E) and minerals (iron, calcium, copper, zinc, magnesium, and others) in controlling the symptoms and signs of OSMF. Significant improvement in symptoms, notably intolerance to spicy food, burning sensation, and mouth opening was observed. Maher R, Aga P, Johnson NW, Sankaranarayanan R, Warnakulasuriya S. Evaluation of multiple micronutrient supplementation in the management of oral submucous fibrosis in Karachi, Pakistan. Nutr Cancer. 1997;27:41–7 • Borle et al. reported that Vitamin A, 50,000 IU chewable tablets, if given once daily could cause symptomatic improvement. Trismus did not improve with this treatment. Borle, R.M. and Borle, S.R. Management of oral submucous fibrosis. Am. Assoc. Oral Maxillofacial Surgeons.1991. 49, 788-791. 8/6/2016 37
  • 38. BRAND NAME CAP.ANTOXID(1 cap.tid for first 2 months and then 1 cap.od )  Beta Carotene 30 mg, Manganese 2 mg, Copper sul. 1 mg, Zinc Sulphate 27.5 mg, Selenium 200 mcg. CAP.SM FIBRO  Lycopene 5 mg+Betacarotene 10 mg +Selenium 75 mcg +zn sul 27. 5 mg+Copper sul. 1 mg +Alpha lipoic acid 50 mg +Alpha tocopheryl acetate 10 IU 8/6/2016 38
  • 39. The Role of Vitamin-E in Cancer Chemoprevention • Many past studies suggest the role of antioxidant (vitamin-E) in treatment of oral mucosal lesions particularly includes oral leukoplakia, oral lichen planus, oral submucous fibrosis and oral cancer. Iqbal et al.Role of Vitamin E in Prevention of Oral Cancer:-A Review.J Clin Diagn Res. 2014; 8(10): ZE05–ZE07 Main action of vitamin E includes increase immunity, controls free radicals mediated cell disturbances, maintains membrane integrity, inhibit cancer cell growth, cytotoxicity. • Inhibits oral cavity carcinogenesis. • Reduces the risk of developing oral cancer. • Prevent development of neurological abnormalities. 8/6/2016 39
  • 40. • One study carried out which highlighted the role of Vitamin-E in oral submucous fibrosis. Plasma Vitamin-E level was found to be decreased in grade II and III OSMF cases but not in grade I cases. However, mean Vitamin-E level was found to be decreased (9.3 ± 0.3 mg/L) as compared to healthy controls (mean = 10.1 ± 1.2 mg/L). Enzymatic antioxidant defense was assessed by SOD activity, which did not show any significant change in any stage of the disease. Gupta S, Reddy MVR, Harinath BC. Role of oxidative stress and antioxidants in aetiopathogenesis and management of oral submucous fibrosis. Indian Journal of Clinical Biochemistry. 2004;19:138–41 8/6/2016 40
  • 41. LYCOPENE  Lycopene is a major carotenoid obtained from tomato with potent anticancer activity.  Lycopene is one of the most potent antioxidants, with a singlet-oxygen-quenching ability twice as high as that of β- carotene and 10 times higher than that of α-tocopherol. Actions-  Inhibition of cancer cell proliferation.  Interference with GF stimulation of cancer cell proliferation.  Cancer prevention by inducing phase 1 enzymes(removal of carcinogenes)  Regulation of transcription.  Restoration of gap junctions by upregulating the expression of connexin (cx43 gene) 8/6/2016 41
  • 42. 8/6/2016 42 Sanadi et al. lycopene: it’s role in health and disease , IJPSR, 2012; Vol. 3(12): 4578-4582
  • 43. • In one study, 58 were randomly divided into 3 groups, evaluated weekly over a 2-month period. Patients of group A (n = 21) received 16 mg of lycopene, those of group B (n = 19) received 16 mg of lycopene along with biweekly intralesional steroid injections, and those of group C (n = 18) were given a placebo. • Results showed that mouth-opening values for the patients showed an average increase of 3.4 mm, 4.6 mm, and 0.0 mm for patients in groups A, B, and C, respectively. The authors concluded that lycopene should be used as a first line of therapy in the initial management of oral submucous fibrosis. Kumar A, Bagewadi A, Keluskar V, Singh M. Efficacy of lycopene in the management of oral submucous fibrosis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2007 Feb;103(2):207-13 8/6/2016 43
  • 44. • In another study included 92 patients with OSMF. Out of 92, 46 patients were given lycopene and remaining 46 were on placebo drug. • Lycopene group patients received 8 mg Lycored per day in two divided doses of 4 mg each, while placebo group patients received placebo tablet twice a day. Patients were examined for changes in mouth opening and other clinical symptoms of OSMF during 3 months and were followed up for next 2months.The results showed that Lycopene was found to be significantly efficacious in the amelioration of signs and symptoms of OSMF. Karemore TV, Motwani M. Evaluation of the effect of newer antioxidant lycopene in the treatment of oral submucous fibrosis. Indian J Dent Res 2012;23:524-8 8/6/2016 44
  • 45. Dose  Based on previously reported studies; a daily intake of 25-30 mg lycopene was initially suggested . Rao V and Heber D, Future directions and intake recommendations; Caledonian Science Press, Scotland U.K., 2001, 43 8/6/2016 45
  • 46. • A fully randomized, cross-over design was used in this study. Tomato ketchup used in the study was provided by H.J.Heinz Company. A standardized single serve pouch of ketchup (8ml) contained 1 mg of lycopene. Lyc-O-Mato (an oleoresin based lycopene capsule) Subjects underwent a one-week run-in period during which they consumed their regular diet, and maintained a 7-day diet record. • After 2-week washout phase during which they were asked to consume their regular diet, but refrained from consuming any tomatoes, processed tomato products and other sources of lycopene. Following the washout phase, subjects were asked to consume one of the test materials (5,10,20 mg) lycopene as tomato ketchup and 5, 10, 20 mg lycopene as Lyc-O-Mato capsule) along with their regular diet for 2 weeks. Following the 2-week treatment period, subjects again underwent a 2- week washout phase prior to the second treatment phase 8/6/2016 46
  • 47. • They did not consume any source of lycopene other than those provided during the entire period of the study. • A significant increase in serum lycopene level was observed for both ketchup and capsules at all levels of intake. Based on these results an intake of 5 to 10 mg lycopene per day is recommended. Rao AV, Shen H (2002). Effect of low dose lycopene intake on lycopene bioavailability and oxidative stress. Nutr Res 22, 1125–1131. Brand name-Cap licoray plus- lycopene 2000 mcg. Lycomin-lycopene 5000 mcg,lycored-lycopene 2000 mcg. 8/6/2016 47
  • 48. Spirulina • Spirulina is a microalgae with rich natural source of proteins, carotenoids and other micronutrients. • The chemopreventive capacity to reverse precancerous lesions of spirulina is attributed to the antioxidant property with high amount of beta carotene and superoxide dismutase. • An intervention study was conducted on 40 oral submucous fibrosis cases,divided into two groups, group A (spirulina group) and group B (placebo group). Group A received spirulina 500 mg twice daily and biweekly intralesional steroid injection of Betamethasone 4 mg/ml for 3 months and group B was given placebo capsules twice daily and biweekly intralesional steroid injection of Betamethasone 4 mg/ml for 3 months. 8/6/2016 48
  • 49. s• Clinical improvements in mouth opening was significant in the post treatment period in both Spirulina and placebo groups. Both the groups showed statistically significant reduction in burning sensation. However, when both groups were compared, mouth opening and burning sensation was found to be statistically very highly significant in favor of the spirulina group. Shetty P, Shenai P, Chatra L, Rao PK. Efficacy of spirulina as an antioxidant adjuvant to corticosteroid injection in management of oral submucous fibrosis. Indian J Dent Res 2013;24:347-50 8/6/2016 49
  • 50. • In another study,68 subjects with clinico-pathologically diagnosed OSMF were included in the study They were divided equally in two groups, Group A (spirulina group) and Group B (lycopene group). Group A was administered 500 mg spirulina in two divided doses for 3 months, and Group B was given 8 mg lycopene in two divided doses of 4 mg for 3 months. • The patients in both the groups showed improvement in all the parameters measured. Clinical improvements in mouth opening was significant in Group B ,whereas ulcers/erosions/vesicles significantly improved in the Group A. 8/6/2016 50
  • 51. The authors concluded that Lycopene can bring about significant clinical improvements in the symptoms like mouth opening, while spirulina can significantly improve ulcers/ erosion/ vesicles. Both the drugs also showed improvement in pain associated with the lesion and burning sensation. Patil S, Khandelwal S, Maheshwari S. Comparative efficacy of newer antioxidants spirulina and lycopene for the treatment of oral submucous fibrosis. Clin Cancer Investig J 2014;3:482-6 Brand names • Holy-health (cap), herbal hills(cap), jiaze (tablets) 8/6/2016 51
  • 52. ALOE VERA • Aloe vera is a mannoprotein containing many amino acids known as 'wound healing hormones'. • The polysaccharides contained in the gel of the leaves, promote wound healing and have anti-inflammatory, immunomodulatory, antioxidant, and gastro-protective properties. Further, sterols in aloe vera have strong ability to inhibit inflammation similar to the action of cortisone without any side effects. It can be found easily and is of low cost in India. 8/6/2016 52
  • 53. • 20 study subjects with OSMF were included in the study. Patients were divided into two groups. There were 10 patients in each group; group A subjects received 5 mg of aloe vera gel to be applied topically three times daily for 3 months and group B subjects received antioxidant capsules twice daily for 3 months. • The results showed that Aloe vera responded better in all the parameters assessed and responded in all the clinicohistopathological stages particularly in those with mild- stage clinically and early-stage histopathologically. Aloe vera showed a statistically significant reduction in burning sensation (P = 0.008), improvement in mouth opening (P = 0.02), and cheek flexibility (P = 0.01) on comparing with the antioxidant group. Sudarshar R et al. Aloe vera in the treatment for oral submucous fibrosis – a preliminary study J Oral Pathol Med (2012) 41: 755–761 8/6/2016 53
  • 54. • In another study 120 clinicopathologically diagnosed OSMF patients, were included in the study. They were divided equally into, Group A (lycopene group) and Group B (aloe vera group). Group A was administered 8mg lycopene in two divided doses of 4mg daily and Group B was given 5mg aloe vera gel to be applied topically thrice daily for 3 months. • The results showed that though, there is no definitive treatment for the condition; however, lycopene can bring about significant clinical improvements in the symptoms like mouth opening and tongue protrusion when compared to aloe vera. Both the drugs appear to be promising in the treatment of OSMF. Patil S, Sghaireen M G, Maheshwari S, Kunsi SR, Sahu R. Comparative study of the efficacy of lycopene and aloe vera in the treatment of oral submucous fibrosis. Int J Health Allied Sci 2015;4:13-7 8/6/2016 54
  • 55. Turmeric • Turmeric acts by decreasing the number of micronuclei in the circulating lymphocytes and by acting as an excellent scavenger of free radicals. Taneja L, Nagpal A, Vohra P, Arya V. Oral submucous fibrosis: An oral physician approach. J Innov Dent 2011;1:14-18 • The anti-inflammatory and antioxidant properties of curcumin are responsible for its chemopreventive action. • It has been seen that curcumin lowers the activity of STE (smokeless tobacco extract)- or NNK (nicotine derived nitrosamine ketone)-induced NF-κB (nuclear factor kappa- light-chain-enhancer of activated B cells) and COX-2 in oral premalignant and cancer cells. Rai B, Kaur J, Jacobs R, Singh J. Possible action mechanism for curcumin in pre-cancerous lesions based on serum and salivary markers of oxidative stress. J Oral Sci 2010;52:251-6 8/6/2016 55
  • 56. • The anti-inflammatory and antioxidant activities of curcumin have been observed in in vitro studies that showed the inhibition of lipo-oxygenase and cyclo-oxygenase (COX) activities that can induce inflammation. • Dose –cap 500 mg tid for 3 months. 8/6/2016 56
  • 57. • One study carried out that includes 30 subjects diagnosed with OSMF. The patients were administered commercially available turmeric; their mouth opening and burning sensation on VAS scale were evaluated at regular intervals, and the data was then compared. The improvement in mouth opening was not significant; however, the change in burning sensation on VAS was significant. Agarwal N, Singh D, Sinha A, Srivastava S, Prasad RK, Singh G. Evaluation of efficacy of turmeric in management of oral submucous fibrosis . J Indian Acad Oral Med Radiol 2014;26:260-3 8/6/2016 57
  • 58. • Another studied the effect of turmeric oil (600mg), alcohol extracts of turmeric (3g) and turmeric oleoresin (600mg) on cytogenetic damage in patients suffering from OSMF after daily intake for 3 months. They concluded that turmeric oil and turmeric oleoresin both act synergistically in vitro to offer protection against DNA damage. Thus, curcumin holds a promising future in the treatment of OSMF. Hastak K, Lubri N, Jakhi S.D. Effect of turmeric oil and turmeric oleoresin on cytogenic damage in patients suffering from oral submucous fbrosis. Cancer Letters; 116: 265-9,1997. 8/6/2016 58
  • 60. ALPHA LIPOIC ACID • Alpha lipoic acid (also called thioctic acid) has been claimed to be the near-perfect antioxidant. • Alpha lipoic acid is able to scavenge more free radical cells than most other antioxidants, the majority of which tend to dissolve in either fat or water but not both. • A case-control study was conducted on 18 patients of OSMF (9 cases and 9 controls). The case group was treated using alpha lipoic acid in addition to the intralesional steroid and hyaluronidase injections used in the control group. 8/6/2016 60
  • 61. • The results showed that the cases in the alpha lipoic acid group exhibited better relief of symptoms such as burning sensation of the mucosa and mouth opening, as compared to the controls. The use of alpha lipoic acid along with intralesional steroids and hyaluronidase caused reversal of higher clinical stages to lower ones. Rao PK. Efficacy of alpha lipoic acid in adjunct with intralesional steroids and hyaluronidase in the management of oral submucous fibrosis. J Can Res Ther 2010;6:508-10 • Alpha-lipoic acid 100 mg, 1 capsule per day for 30 days has shown reduction in burning sensation and improved mouth opening. Shetty DN, Shenai P, Chatra L. Oral Submucous Fibrosis: Review of Modalities of Management. Indian Dentist Research and Review.2010;66-70 8/6/2016 61
  • 62. Acetic acid • Periodic swabbing of oral mucosa with house hold vinegar acetic acid at ph 6.5 using a cotton applicator provide symptomatic relief in some patients. • It causes swelling of most of the tissues,capable of dissolving non-cross linked molecules and cross linked collagen fibres Altered collagen attracting macrophages Scavanging action promoting collagenolysis. A.K verma .Volume 4 tobacco counters health.1st ed.2006 8/6/2016 62
  • 63. Role of physiotherapy • Kneading is an effective form of massage therapy in improving the elasticity of fibrous tissues and mobilizing scar tissues. The gentle soft tissue manipulation is extensively used in physiotherapy for improving their extensibility. • The decrease in TMJ mobility is mobilized by forced passive movements & manipulations to permit more mouth opening. Vijayakumar M, Priya D. Physiotherapy for improving mouth opening & tongue protrution in patients with Oral Submucous Fibrosis (OSMF) – Case Series. International Journal of Pharmaceutical Science and Health Care. 2013;2(3): 50-58. 8/6/2016 63
  • 64. Muscle streching exercise • This may be helpful to prevent further restriction of mouth movements and to prevent relapse. This can be performed using mouth gag, acrylic surgical stent, ballooning of mouth, hot water gargling, inter positioning spatula between the teeth and adding a new spatula every 5-10 days. • This is thought to put pressure on fibrous bands. • It is advocated to use the oral stents over a period of 6 months. It should be removed only while during meals and at bedtime otherwise the patient should wear it all day. Vijayavel. T, Ponni V. management for oral submucous fibrosis – A comprehensive review. Indian Journal of Multidisciplinary Dentistry. 2014; 4(1): 869-874. 8/6/2016 64
  • 66. • A 26-year-old man diagnosed with OSMF (mouth opening at interincisal level: 34 mm), gave a personal history of a habit of pan-masala chewing (∼40 g/day) for 2 years. He was treated with the MED ,followed every month for next 6 months, after which the patient’s mouth opening was improved to 41 mm. Patil PG , Patil SP. Novel Mouth-Exercising Device for Oral Submucous Fibrosis. Journal of Prosthodontics 21 (2012) 556–560 8/6/2016 66
  • 67. Heat –Short wave/Micro wave diathermy: • Heat has been used in the form of lukewarm water, hot rinses or selective deep heating therapies like short wave or micro wave diathermy. • It acts by physiofibrinolysis of bands. • Microwave diathermy at 2450 MC/s daily for 20 mins at each site of the lesion with 20 to 25 watts of energy, 15 sittings were given and reported that the use of microwave diathermy of great significance for moderately advanced stages but in very advanced cases results were very poor. Gupta D, Sharma SC. Oral submucous fibrosis- A new treatment regimen. Oral Maxillofac Surg. 1988; 46: 830-833. 8/6/2016 67
  • 68. Medical management • Interferon gamma • Placental extracts • hyaluronidase • Corticosteroids • Peripheral Vasodilators • Immunised milk • Combination regimen 8/6/2016 68
  • 69. Interferon-gamma (anti-fibrotic cytokine). • Decreases fibrosis(down regulates fibroblast proliferation and collagen synthesis) • Arrest progession of OSMF • Increase mouth opening 15 injections of 50 microgram (0.25 ml ) intralesionally twice a week over 8 weeks Haque et al.Interferon gamma (IFN-gamma) may reverse oral submucous fibrosis. J Oral Pathol Med. 2001;30(1):12-21. 8/6/2016 69
  • 70. In one study investigation is carried out to find • a) the effect of IFN-γ on collagen synthesis by arecoline- stimulated OSF fibroblasts in vitro (n=5), • b) the effect of intra-lesional IFN-γ on the fibrosis of OSF patients (n=29) and • c) the immunohistochemical analysis of pre- and post- treatment inflammatory cell infiltrates and cytokine levels in the lesional tissue (n=29). • The results showed that the increased collagen synthesis in vitro in response to arecoline was inhibited in the presence of IFN-γ (0.01–10.0 U/ml) in a dose-related way. 8/6/2016 70
  • 71. 321`a1236y8i85t5tr5• Also this study showed intra-lesional IFN-γ treatment showed improvement in the patients mouth opening from an inter- incisal distance before treatment of 21±7 mm, to 30±7 mm immediately after treatment and 30±8 mm 6-months later, giving a net gain of 8±4 mm (42%) (range 4–15 mm). Patients also reported reduced burning dysaesthesia and increased. Haque et al.Interferon gamma (IFN-gamma) may reverse oral submucous fibrosis. J Oral Pathol Med. 2001;30(1):12-21. 8/6/2016 71
  • 72. Placental extract(placentrex) • Placental extract contains growth factors and anti- inflammatory agents and it has shown to have anti- inflammatory and anti-platelet activity. • It is an aqueous extract of human placenta that contains nucleotides, enzymes, vitamins, aminoacids & steroids. It acts by “Biogenic stimulation” which  Acclerates cellular metabolism through pituitary adreno cortical axis.  Assist in the absorption of exudates,stimulates the regeneration process.  Increase the physiological action of organs.  Increase blood circulation by increasing tissue vascularity. 8/6/2016 72
  • 73. Its use is based on the method of “tissue therapy” introduced by Filatov in 1933. No contraindications & the results are found to be lasting. Available in 4 forms  Aqueous solution of human placenta  Lipoid extracts  Immuno-gamma globulins  Tissue coagulants 8/6/2016 73
  • 74. • The authors presented a case report of 12-year-old girl with interincisal distance of maximal mouth opening was 1.7 cm. she was advised to stop chewing areca nuts. Submucous (intralesional) injection of aqueous extract of healthy human placenta (Placentrex, 2 ml) was given for two months to the regions with palpable fibrotic bands. • The procedure was repeated at an interval of three days. Each time, 2 ml of solution was deposited around the specific region on both sides. There was a remarkable improvement in the burning sensation of the mouth and moderate improvement in mouth opening. Anil S,Beena MT. Oral submucous fibrosis in a 12-year- old girl: case report. Pediatric Dentistry; 1993 -16(2).120-22 8/6/2016 74
  • 75. • In another study 15 patients with clinico-pathologically diagnosed OSMF were included in the study. Patients were divided randomly into three groups and betamethasone, placental extract & hyaluronidase intralesional injection was given to the separate groups of the patient for a period of 8 weeks. • Mouth opening and burning sensation was recorded clinically & subjective lymprovement in mouth opening was observed the maximum with intra lesional injection of hyaluronidase with 9.38mm in average,followed by placentrex and improvement in burning sensation was observed maximum with intra lesional injection of betamethasone. Gupta J.et al.Effiacy of betamethasone, placental extract and hyaluronidase in the treatment of osmf: a comparative study. E- Journal of Dentistry;Jan2012, Vol. 2 Issue 1, p132 8/6/2016 75
  • 76. • Another study comprise 10 subjects with oral submucous fibrosis who presented with mouth opening less than 20 mm were enrolled in the present prospective randomized controlled trial to assess the effects of placental extract on the fibrotomy wound covered with a pedicled buccal pad fat (5 patients allocated to the study group, group S and 5 to the control group, group C) • The results showed that the average difference in the preoperative and 4TH week postoperative mouth opening for group C was 13.8 ± 2.68 mm and was 21.20 ± 2.77 mm in group S. The median calculated for group C was a 15-mm increase in mouth opening and was 20 mm in group S. 8/6/2016 76
  • 77. • The results obtained with topical application of placental extract on fibrotomy wound healing and postoperative mouth opening were superior to those of the control group in whom placental extract was not used. Thakur.G et al.Does Topical Application of Placental Extract Gel on Postoperative Fibrotomy Wound Improve Mouth Opening and Wound Healing in Patients With Oral Submucous Fibrosis? J.oral max.surg.july.2015. 1439.e1–1439.e10 8/6/2016 Template copyright 2005 www.brainybetty.com 77
  • 78. • In combination therapy ,a 33-year-old male patient with OSMF was given triamcinolone 1 ml (10 mg/ml) + hyaluronidase 1500 IU + placentrex 2 ml] given in fragmented doses. After a period of 2 months, the patient had noticed improvement in the burning sensation of mouth with a feeling of well-being. His interincisal opening had increased significantly. Bhushan KI,Sethi AK.A rare ocular complication following treatment of oral submucous fibrosis with steroids.Natl J Maxillofac Surg. 2011 Jan-Jun; 2(1): 93–95. 8/6/2016 78
  • 79. Placentrix -2cc biweekly for 10 weeks in combination with dexamethasone and hyaluronidase. Gupta D, Sharma SC. Oral submucous fibrosis--a new treatment regimen. J Oral Maxillofac Surg. 1988;46:830–3. 2cc of placentrix injection intralesionally at weekly intervals for 10 weeks was found to be superior to cortisone. In resistant cases, surgical excision of fibrotic bands with submucosal placement of fresh human placental grafts was found to be successful. Shetty DN, Shenai P, Chatra L. Oral Submucous Fibrosis: Review of Modalities of Management. Indian Dentist Research and Review.2010;66-70. 8/6/2016 79
  • 80. Hyalouronidase Reduces burning sensation & trismus. Acts by breaking down hyaluronic acid, lowers the viscosity of intracellular substances. Decreases collagen formation. “The combination of steroids & hyaluronidase shows better long-term results than either agent used alone.” (Kakar, 1985) 8/6/2016 80
  • 81. • It is recommended that triamcinolone acetonide (10 mg/ml) combined with 1500 IU of hyaluronidase should be given intralesionally particularly in retromolar trigone area half dose each side at 15 days interval for a total of 11 injections in 22 wk. Singh et al.Efficacy of hydrocortisone acetate/hyaluronidase vs triamcinolone acetonide/hyaluronidase in the treatment of oral submucous fibrosis Indian J Med Res 131, May 2010, pp 665-669 • A total of 28 patients treated by administering an intralesional injection of dexamethasone1.5 ml, hyaluronidase 1500 IU with 0.5 ml lignocaine HCL injected intralesionally biweekly for 4 weeks. Improvement in the patient’s mouth opening with a net gain of 6 ± 2 mm (92%), the range being 4-8 mm. Defi nite reduction in burning sensation, painful ulceration and blanching of oral mucosa and patient followed up for an average of 9 months. 8/6/2016 81
  • 82. • The authors concluded that the injection of hyaluronidase with dexamethasone is an eff ective method of managing Grade III OSMF and can possibly eliminate the morbidity associated with surgical management. James L. et al.Management of Oral Submucous Fibrosis with Injection of Hyaluronidase and Dexamethasone in Grade III Oral Submucous Fibrosis: A Retrospective Study. Journal of International Oral Health 2015; 7(8):1-4 8/6/2016 82
  • 83. • In combination therapy 100 patients with OSMF were randomly divided into two groups. Group A patients received combination of hydrocortisone acetate (1.5 ml)/hyaluronidase (1500 IU) at weekly interval submucosally in pterygomandibular raphe, half dose on each side for 22 wk. Group B patients received combination of triamcinolone acetonide (10 mg/ml)/ hyaluronidase (1500 IU) at 15 days interval for 22 wk. • Treatment outcome was evaluated on the basis of improvement in symptom score, sign score and histopathological improvement. Treatment regimen of group B was more convenient to the patients because less number of visits required and cheap. No side effects were seen. A follow up study is required to see long term effects. • Singh M.et al. Efficacy of hydrocortisone acetate/hyaluronidase vs triamcinolone acetonide/hyaluronidase in the treatment of oral submucous fibrosis. Indian J Med Res 131, May 2010, pp 665-669 8/6/2016 83
  • 84. Brand names • Facidase 1500 IU X 2 ml. • Hylorase 1500 IU 8/6/2016 84
  • 85. Intra-lesional steroids • Steroids also prevent or suppress inflammatory reactions thereby preventing fibrosis by decreasing fibroblastic proliferation and deposition of collagen. • The initial symptomatic relief could be due to the anti- inflammatory action of the steroids, which helps in clearing the juxtaepithelial inflammatory reaction. Elluru Venkatesh et al .Archives of Dental Sciences Role of Corticosteroids in Dentistry 2010,Vol.1,Issue1, 03-11 8/6/2016 intr 85
  • 86. • Inhibit pg synthesis • Anti-inflammatory • Inhibit DNA synthesis of fibro-epithelial cells • Inhibit collagen synthesis. Ponec M et al. Effects of glucocorticosteroids on primary human skin fibroblasts. Archives of dermatological research.1977; 259,(2), 125-134 • Steroids exhibit dose dependent enhancement in the proportion of phagocytic cells which phagocytose collagen and fibronectin Tsai CC, Ma RH, Shieh TY. Deficiency in collagen and fibronectin phagocytosis by human buccal mucosa fibroblasts in vitro as a possible mechanism for oral submucous fibrosis. J Oral Pathol Med 1999; 28: 59-63 8/6/2016 86
  • 87. • Submucosal injections of a combination of dexamethasone (4 mg/l0ml) and 2 parts of hyaluronidase (200 u.s.p unit/ml) diluted in 1 ml of 2 % xylocaine by means of a 27 gauge dental needle, not more than 0.2 ml solution/site for a period of 20 weeks. • Similarly submucosal injection of triamcinolone 10 mg /ml diluted in 1 ml of lidocaine 2 % to avoid immediate tissue irritation and to facilitate proper distribution of drug to al the sites biweekly can be used. • Borle R M, Borle S R, Management of oral submucous fibrosis-A conservative approach. JOMS 1991; 49:788-91. 8/6/2016 87
  • 88. 8/6/2016 Template copyright 2005 www.brainybetty.com 88
  • 89. • A total of 28 patients diagnosed with OSMF were treated in for a time period of 9 months by administering an intralesional injection of dexamethasone1.5 ml, hyaluronidase 1500 IU with 0.5 ml lignocaine HCL injected intralesionally biweekly for 4 weeks. • Results showed there is Improvement in the patient’s mouth opening with a net gain of 6 ± 2 mm (92%), the range being 4- 8 mm. Definite reduction in burning sensation, painful ulceration and blanching of oral mucosa and patient followed up for an average of 9 months. The authors concluded that Injection of hyaluronidase with dexamethasone is an effective method of managing Grade III OSMF and can possibly eliminate the morbidity associated with surgical management. • James L et al.Management of Oral Submucous Fibrosis with Injection of Hyaluronidase and Dexamethasone in Grade III Oral Submucous Fibrosis: A Retrospective Study.j int oral health.20157(8):1-4 8/6/2016 89
  • 90. • IMMUNE MILK- Immune milk is a kind of skimmed milk produced from cows immunised with multiple human intestinal bacteria. • It has good anti-inflammatory effect & contains moderate amounts of Vit. A, C, B1, B2, B6, B12, nicotinic acid, pantothenic acid, folic acid, iron, copper & zinc. • Though chemically its identical to commercial milk but it contains 20-30% higher concentration of IgG type 1 antibody. • 45gms of immunised milk powder twice a day, for 3 months showed significant improvement in symptoms of OSMF. Tai YS.et al 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. J Oral Pathol Med.2001 Nov;30(10):618-25. 8/6/2016 90
  • 91. • In this preliminary study, 26 OSMF 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 OSMF patients who received only oral habit intervention served as the control group. Interincisor distance was significantly improved (> or =3 mm of the baseline measurement) in 18 of the 26 (69.2%) OSMF patients in the experimental group at exit. However, in the control group ,none of the OSMF patients had an increase in interincisor distance greater than 2 mm. The authors concluded that oral administration of immune milk leads to significant improvements of symptoms and signs in OSF patients. Tai YS.et al 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. J Oral Pathol Med. 2001 Nov;30(10):618-25. 8/6/2016 91
  • 92. Immuno-modulatory drugs Antigen Sensitized lymphocytes Inflammatory reaction Fibroblast proliferation Increased collagen synthesis 8/6/2016 92 Immuno- modulators
  • 93. Levamisole Immuno-modulatory drug, given at a dose of 50 mg tab (TID) showed significant improvement in signs and symptoms. It modifies both cellular and humoral immunity, has an Anti- inflammatory effects and its ability to modulate inflammatory cytokines reduces burning sensation. Jirge V, Shashikanth MC, Ali IM, Nisheeth A. Levamisole and antioxidants in the management of oral submucous fibrosis: A comparative study. J Indian Acad Oral Med Radiol. 2008;20:135–40. Balaji rao et al.1993 levamisole 150 mg-once daily for 3 days in a week for 6-8 weeks 8/6/2016 93
  • 94. Peripheral vasodialator Pentoxifylline (Trental) • It has anti inflammatory properties like altering fibroblast physiology, suppressing leucocyte function and stimulating fibrinolysis. • Its immuno-modulating actions include neutrophil degranulation, increasing leukocyte adhesion, promotes natural killer cell activity, release of peroxides, production of tumor necrosis factor and inhibits T and B cell activation. • Pentoxifylline 400 mg three times daily, as coated, sustained release tablets have been used as an adjunct therapy resulted in improvement in mouth opening, tongue protrusion, and relief from perioral fibrotic bands. • Shetty DN, Shenai P, Chatra L. Oral Submucous Fibrosis: Review of Modalities of Management. Indian Dentist Research and Review.2010;66-70 8/6/2016 94
  • 95. Nylindrin hydrochloride  Sharma JK et al.1987 recommended the use of nylindrin hydrochloride which is a peripheral vasodialator that reduces ischaemia.  Used in combination therapy. nylindrin hydrochloride+vit A,E,B complex+placental extract+steroids+physiotherapy 8/6/2016 95
  • 96. Lasers • The ErCr:YSGG (waterlase C-100) laser was used to release the fibrotic bands of OSMF that were causing limited mouth opening. • It works on "hydro-photonic process" in which the laser energy from the ErCr:YSGG is able to interact with water droplets at tissue to create water molecule excitation. This, in turn, causes water droplet micro-expansion and propulsion that gives clean and precise hard-tissue cut. • Analgesics,anti-inflammatory and muscle –relaxing effect. 8/6/2016 96
  • 97. ULTRASOUND. • During ultrasound therapy, cell membrane permeability is increased by altering sodium and potassium ion gradients. This increased permeability improves gas exchange and promotes healing. • It increases vasodilatation. • accelerates lymph flow • decreases inflammation and stimulates metabolism. • Ultrasound used for therapeutic purpose has a frequency of about 0.8-1 MHz and an intensity of 0.5-3 w/cm2. 8/6/2016 97
  • 98. • Ultrasound treatment accelerate healing, increase the extensibility of collagen fibers, provide pain relief and selectively raises the temperature in some well circumscribed areas. • Ultrasound of dose ranging from 0.6 to 2.0 W/Cm2 pulsed 1:1 or 1:2 ( 50% or 33.3 % duty cycle), Frequency of 3 MHz, 5cm diameter transducer head for 3 to 4 minutes to each side over the cheek for 15 consecutive days with permissible one day off each week. Vijayakumar M, Priya D. Physiotherapy for improving mouth opening & tongue protrution in patients with Oral Submucous Fibrosis (OSMF) – Case Series. International Journal of Pharmaceutical Science and Health Care. 2013;2(3): 50-58. 8/6/2016 98
  • 99. Surgical treatment • Motawetz G.1987.-Excision of fibrotic bands with sub- mucosal placements of human skin grafts. • Gupta and sharma et al 1988. Excision of fibrotic bands with sub-mucosal placements of human placental grafts. • Khanna and Andrade 1996-in advanced cases bilateral temporal myotomy,bilateral coronoidectomy and palatal island flap. 8/6/2016 99
  • 100. Grading and treatment modalities Gupta DCS et al. • Grade I-Only blanching of oral mucosa without symptoms. • Grade II-Burning sensations ; Dryness of mouth ;vesicles / ulcers in the mouth without tongue involvement. • Grade III- In addition to grade II restriction of mouth opening . • Grade IV- In addition to grade III palpable bands all over the mouth without tongue involvement Grade V and tongue involvement . • GradeVI-Oral submucous fibrosis along withhistologicaly proven oral cancer. 8/6/2016 100
  • 101. GROUP I : : Removal of etiological factors Discontinuation of habits ( paan, beetel nut, tobacco chewing and intake of spicy food ) Nutritional Therapy : Multivitamin therapy and Iron therapy to boost up the nutritional status of the patients. GROUP II : Topical Therapy patient's in grade I & II and to prevent relapse after other treatment modalities. • Triamcinolone acetate 0.1 % with neomycin - to be applied to the oral mucosa three times daily and the patients were advised to let the saliva drool for 15 minutes. • This one month course was repeated after two months. Pappain and urea mixture : to be applied intra orally 2-3 times daily for 15 days and to be repeated after one month 8/6/2016 101
  • 102. • Papain mixture : The mode of action of papain mixture is by biogenic stimulation and the proteolytic action. • UREA : keratolytic agent, induces surface lysis of keratin layer of oral mucosa and early absorption at the lesional site , breaking the fibro peptide linkages of the fibrous layer, leading to slight laxity of the oral mucous membrane stiffness • GROUP III -Injectable therapy : For patients in grade III, IV, V Injectable Hyaluronidase 1500 I.U, 0.5 ml injected intra lesionally twice a week for 10 weeks. 8/6/2016 102
  • 103. • Dexamethasone 1.5 ml with 0.5 ml of lignocaine HCL intra lesionally biweekly for 5 weeks. • Placental extracts (PLACENTRIX) -2 ml intra lesionally once a week for 4 weeks ; along with injection ranidone ( Iodine & vit B complex ) I.M • HYALURONIDASE causes collagen destruction as collagen of OSMF patients ( as compared to controls) is attacked rapidly by Hyaluronidase. Also it breaks down Hyaluronic acid and causes lowered viscosity of intercellular cementing substance 8/6/2016 103
  • 104. • STEROIDS -functions as immune suppressive agents by opposing the action of the soluble factors released by the sensitized lymphocytes following activation by non specific antigens. Also suppresses the inflammatory reaction. Thus fibrosis is prevented by a decrease in fibroblastic proliferation and deposition of collagen. • Placentrix : Acts by biogenic stimulation. • Ranidone , an iodine and vit B complex preparation stimulates the metabolic processes in the body. • Vit B complex potentiates the action of Iodine and makes it non toxic. 8/6/2016 104
  • 105. GROUP IV-Micro wave Diathermy using " microtone 200 " unit producing microwaves of 2450 MC / S : for patients in grade IV & V • One sitting of 20 min a day for 15 days to give an energy of 20 watts . • Microwave Diathermy causes physio fibrolysis of bands. 8/6/2016 105
  • 106. GROUP V : Surgical treatment for patients with grade IV & V or with isolated bands in retromolar region and in patients in grade VI • Forceful mouth opening : Patients with severe trismus and having unerupted / partially erupted 3rd molars had their mouth forcefully opened, and the patients were asked to apply Kamillosan ointment to reduce scar formation and promote healing. Topical steroids are used to prevent relapse. • Rotated tongue flap or skin grafting- for patients with Isolated bands in retromolar region and trismus . • Gupta Dinesh Chandra S, Dolas Rameshwar S, Ali Iqbal. Treatment of Oral submucous fibrosis : How they stand today? A Study of 600 cases. Ind J of Oral and Maxillo surg 1992(7);43. • 8/6/2016 106
  • 107. 8/6/2016 107 KoneruA et al.A systematic review of various treatment modalities for oral submucous fibrosis Journal of Advanced Clinical & Research Insights (2014), 2, 64–72
  • 108. References  Greenberg MS, Glick M, Ship JA. Burket’s Oral Medicine.11th edition.Ontario:BC Decker Inc;2003.p. 88-89  Shafer’s textbook of oral pathology-6th ed  Neville oral pathology  Rajlalitha P.Vali . S.Molecular pathogenesis of oral submucous fibrosis – a collagen metabolic disorder. J Oral Pathol Med (2005) 34: 321–8  Sanadi et al. lycopene: it’s role in health and disease , IJPSR, 2012; Vol. 3(12): 4578-4582  . Murti PR, Bhonsle RB, Gupta PC , Daftari DK, Pindborg JJ, Mehta FS. Etiology of oral submucous fibrosis with special reference to role of arecanut chewing. J. Oral Pathol Med. 1995; 24: 145-52. 8/6/2016 108
  • 109. • Gupta Dinesh Chandra S, Dolas Rameshwar S, Ali Iqbal. Treatment of Oral submucous fibrosis : How they stand today? A Study of 600 cases. Ind J of Oral and Maxillo surg 1992(7);43. • Singh et al.Efficacy of hydrocortisone acetate/hyaluronidase vs triamcinolone acetonide/hyaluronidase in the treatment of oral submucous fibrosis Indian J Med Res 131, May 2010, pp 665-669  Phatak A. Fibrin producing factor in Oral Submucous Fibrosis. Indian Journal of Otolaryngology and Head & Neck Surgery 1979; 31(4):103-4.  Rajendran R, Sugathan C, Remani P, Ankathil R, Vijayakumar T. Cell mediated and humoral immune responses in oral submucous fibrosis. Cancer1986;58(12):2628-31. 8/6/2016 109
  • 110. • Tilakratne WM, Klini Kowski NF, Saku T, Peters TJ, Warnakulasuriya S: Oral submucous fibrosis: Review on etiology and pathogenesis. Oral oncol 2005: 30: 30-32. 8/6/2016 110
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