Proposed clinical classification for oral submucous fibrosis

Synergistic effects of betel quid chewing, tobacco use (in the form of cigarette smoking), and alcohol consumption on the risk of malignant transformation of oral submucous fibrosis (OSF): a case-control study in Hunan Province, China

OBJECTIVES

Oral submucous fibrosis (OSF) is a potentially malignant disorder, wherein 7% to 13% of patients with OSF develop oral squamous cell carcinoma (OSCC) at clinically coincident sites established to have OSF. We aimed at investigating the lifestyle-related risk factors for malignant transformation of OSF.

STUDY DESIGN

A case-control study was conducted among 80 cases with OSF-associated OSCC and 80 controls with OSF but without clinically or histopathologically evident OSCC, recruited from January 2012 to October 2014 in the Xiangya Hospital, Hunan Province, Mainland China.

RESULTS

The odds ratios (OR) for OSCC were 13.3 (95% confidence interval [95% CI]: 3.1-56.4) and 45.1 (95% CI: 9.6-212.9) at the highest exposure of betel quid (BQ) chewing, by duration and frequency, respectively. Higher risks were also found to be associated with the consumption of cigarette (OR = 5.0, 95% CI: 1.7-14.8) and alcohol (OR = 3.1, 95% CI: 1.1-8.6). Adjusted ORs increased substantially among patients who consumed BQ and cigarette or alcohol simultaneously, which were 26.1 (95% CI: 4.0-172.6) and 55.-(95% CI: 1.8-1742.8) at the longest duration, and 160.3 (95% CI: 18.7-11371.2) and 58.1 (95% CI: 2.4-1434.9) at the highest dose, respectively.

CONCLUSIONS

The use of BQ, cigarette, and alcohol were identified as risk factors for malignant transformation of OSF in the Hunan province, Mainland China. Synergistic effects between BQ chewing and cigarette or alcohol consumption were revealed.

Comparative evaluation of natural antioxidants spirulina and aloe vera for the treatment of oral submucous fibrosis

AIM

Oral submucous fibrosis (OSMF) is a high risk premalignant condition predominantly seen in the Indian subcontinent. The aim of the present study was to compare the efficacy of spirulina and aloe vera in the management of OSMF.

MATERIAL AND METHODS

42 subjects with clinico-pathologically diagnosed OSMF were included in the study and divided equally in 2 groups, Group A (spirulina group) and Group B (aloe vera group). Group A was administered 500 mg spirulina in 2 divided doses for 3 months and Group B was given 5 mg aloe vera gel to be applied topically thrice daily for 3 months. Evaluation for different clinical parameters was done at regular intervals and data was analyzed using the Chi-square test. P-value <0.05 was considered to be statistically significant.

RESULTS

The patients in Group A showed significant clinical improvement in mouth opening and ulcers/erosions/vesicles (p < 0.05). However, there was no significant improvement in burning sensation (p = 0.06) and pain associated with the lesion (p = 0.04) among the 2 groups.

CONCLUSION

Both the drugs showed improvement in the condition; however spirulina can bring about significant clinical improvements in the symptoms like mouth opening and ulcers/erosion/vesicles. Thus, spirulina appears to be more promising when compared to aloe vera for the treatment of OSMF.

Oral submucous fibrosis--a treatment protocol based on clinical study of 100 patients in central India

PURPOSE

Oral submucous fibrosis till date is a very poorly understood and unsatisfactorily treated disease with variable signs and symptoms. In this paper, we have classified the disease in different groups according to the clinical signs, radiological assessment, histopathological confirmation, progress, and severity of disease and proposed a treatment algorithm for effective treatment of the disease in 100 patients.

MATERIAL AND METHOD

In our study, we randomly selected 100 patients of oral submucous fibrosis and classified them in to five groups based on clinical symptoms and radiological and histopathological parameters. We have given specific treatment for each group and followed them up for 2 years regularly.

RESULTS

We found that almost all patients got symptomatic relief from the disease. Patient's interincisal mouth opening increased significantly. All patients can take regular diet. Progressive malignant transformation can be detected earlier to avoid future morbidity and mortality.

CONCLUSION

Oral submucous fibrosis (OSMF) scoring index is very effective to decide the severity of disease and progress. Based on this scoring and grouping we can give definite prompt treatment to the patients with satisfactory results. Such a way this proposed scoring and staging can play major role in controlling and treating this widespread global disease.

Quantification of Plasma Fibrinogen Degradation Products in Areca Nut Chewers with and without Oral Submucous Fibrosis

INTRODUCTION

Fibrinogen degradation products (FDPs) are the products that are released from fibrin/fibrinogen. Recently, it has been observed that these FDPs have been identified in the plasma of OSMF patients. Areca nut being the major aetiological agent for OSMF may play a role in the increased plasma levels of FDPs in OSMF.

AIM

The aim of this study was to quantify the plasma FDPs levels in the individuals with the habit of areca nut chewing with and without OSMF.

MATERIALS & METHODS

Total of 95 subjects were included,35 subjects with the habit of areca nut chewing with OSMF, 30 with the habit of areca nut chewing without OSMF, 30 without any habit of areca nut chewing without OSMF (control group). Five ml of venous blood was withdrawn from all the subjects and plasma FDP levels were estimated.

RESULTS

Plasma FDPs were detected in all the subjects of OSMF but could not be detected in other two groups. As the clinical grades of OSMF increased, levels of plasma FDPs also increased.

CONCLUSION

When plasma FDP increases, fibrin deposition also increases. This strengthens the finding that these FDPs may be an early indicator of the OSMF.

Eustachian tube dysfunction in OSMF- often present seldom discovered

OBJECTIVES

To evaluate the effect of OSMF on the eustachian tube function and to correlate it with various grades of the disease.

STUDY DESIGN

Twenty OSMF patients (40 ears) and 20 healthy controls (40 ears) were evaluated for eustachian tube function by eustachian tube function test, tympanometry and audiometry.

RESULTS

The audiometric and tympanometric analysis showed no significant differences in hearing abilities of OSMF patients and controls and between various grades of OSMF, indicating no hearing impairment. However, eustachian tube function test revealed a statistically significant difference in eustachian tube function in OSMF patients and controls. Further, there was a significant increase in severity of dysfunction with increase in severity of disease.

CONCLUSIONS

From the present study it is evident that the subjective function of Eustachian tube may be affected by disease process. But, probably the amount of deviation found in function of the eustachian tube is non contributing to cause a conductive hearing loss. Key words:Oral submucous fibrosis, eustachian tube function, tympanometry.

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

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

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

Oral submucous fibrosis and its dermatological relation

Oral submucous fibrosis is a chronic insidious disease and is well-recognized as a premalignant condition. It is a collagen related disorder associated with betel quid chewing and characterized by progressive hyalinization of the submucosa. The oral submucous fibrosis needs to be differentiated from scleroderma showing oral manifestations, as these diseases have different pathogenesis and prognostic aspects. The patients of oral submucous fibrosis can approach the dermatologist. The aim of this article is to present concise overview of the disease and its dermatological relation.

Ultrasonographic evaluation of oral submucous fibrosis in habitual areca nut chewers

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Elevation of S100A4 expression in buccal mucosal fibroblasts by arecoline: involvement in the pathogenesis of oral submucous fibrosis

Background

S100A4, a member of the calcium-binding proteins, is dramatically elevated in a variety of fibrotic diseases. Areca quid chewing is the most important etiological factor in the pathogenesis of oral submucous fibrosis (OSF). OSF has been considered as a pre-cancerous condition of oral mucosa. The aim of this study was to determine the critical role of S100A4 expression in the pathogenesis of OSF both in vitro and in vivo.

Methodology/Principal Finding

Thirty OSF tissues from areca quid chewers and ten normal buccal mucosa samples without areca quid chewing were analyzed by using immunohistochemistry for S100A4 expression in vivo. Collagen gel contraction capability and expression of tissue inhibitor of metalloproteinases 1 (TIMP1)/MMP9 in arecoline-stimulated BMFs with S100A4 knockdown was presented in vitro. Initially, S100A4 expression was higher in areca quid chewing-associated OSF specimens than normal buccal mucosa specimens (p = 0.001). Arecoline, a major areca nut alkaloid, led to dose- and time-dependent elevation of S100A4 expression in normal buccal mucosa fibroblasts BMFs (p<0.05). The additions of pharmacological agents rapamycin (mTOR inhibitor), PD98059 (ERK inhibitor), and Bay117082 (NF-κB inhibitor) were found to inhibit arecoline-induced S100A4 expression (p<0.05) in BMFs. Down-regulation of S100A4 by lentiviral infection significantly reversed arecoline-induced collagen gel contraction and TIMP1/MMP9 expression.

Conclusion/Significance

These results suggest that S100A4 expression is significantly up-regulated in OSF specimens. Arecoline-induced S100A4 expression was down-regulated by rapamycin, PD98059, and Bay117082. Targeting S100A4 might be a potential therapeutic target for OSF through TIMP1/MMP9 down-regulation.

Vasodilator isoxsuprine alleviates symptoms of oral submucous fibrosis

OBJECTIVES

The aim of the study was to compare the effectiveness of vasodilator isoxsuprine to dexamethasone with hyaluronidase injections and physiotherapy in the treatment of oral submucous fibrosis.

MATERIALS AND METHODS

Forty patients with oral submucous fibrosis were randomly assigned into three groups. Group A patients (n = 15) received 10 mg isoxsuprine tablets four times per day, group B (n = 15) biweekly dexamethasone with hyaluronidase intralesional injections, and group C (n = 10) placebo tablets. In addition, all patients were instructed physiotherapy exercises. The treatment time was 6 weeks and patients were followed-up for 4 months thereafter. The effect of the treatment was evaluated by measurements of inter-incisal distance and oral burning sensation and evaluation of histological findings of the diseased mucosa.

RESULTS

Mouth opening increased and burning sensation decreased significantly in all groups, but the effects were significantly greater in groups receiving either oral isoxsuprine or dexamethasone with hyaluronidase injections in addition to physiotherapy. The decrease in burning sensation occurred more rapidly in patients receiving intralesional dexamethasone with hyaluronidase. Histological improvement was not observed in any of the groups.

CONCLUSIONS

Oral isoxsuprine as well as dexamethasone with hyaluronidase injections combined to physiotherapy alleviate symptoms of oral submucous fibrosis significantly more efficiently than physiotherapy alone.

CLINICAL RELEVANCE

Oral isoxsuprine can be considered as a new candidate drug for the treatment of oral submucous fibrosis. Physiotherapy exercises provide relief of symptoms and should be instructed to all patients.