Proposed clinical definition for oral submucous fibrosis

Comprehensive analysis of clinicopathological characteristics in oral squamous cell carcinoma arising from oral submucous fibrosis: a retrospective study

BACKGROUND

Oral squamous cell carcinoma arising from oral submucous fibrosis is recognized as a clinicopathologically distinct disease. This study aims to summarize and compare the population and clinicopathologic characteristics of OSCC-OSF with other OSCC in Hunan Province, China. The objective is to formulate treatment strategies more in line with regional characteristics.

METHODS

A retrospective review of OSCC cases recruited from the Second Xiangya Hospital from 2010 to 2020 was conducted. A total of 1,413 OSCC patients were selected, including 481 patients with OSCC-OSF and 932 were other OSCC. Population characteristics, risk factors and clinicopathological manifestations were explored in OSCC-OSF and other OSCC, as well as thinprep cytologic test and DNA quantification.

RESULTS

We found that OSCC-OSF patients were younger than those with other OSCC. Both types of disease were predominantly observed in males compared to females. Tumor biopsy analysis indicated that tumor cells within OSCC-OSF patients were more likely to be well differentiated and showed a higher frequency of lymph node metastases. Clinicopathological factors, such as the chewing betel nuts habit and smoking, were more prevalent in OSCC-OSF patients in contrast to other OSCC. DNA quantification revealed that the number of DNA aneuploid cells was higher in OSCC-OSF compared to other OSCCs.

CONCLUSION

In this study, OSCC-OSF is considered a clinicopathologically distinct disease. Compared with other OSCC, OSCC-OSF patients have a higher incidence of nodal metastases, an early clinical TNM stage, and a lower three-year survival rate. Therefore, early diagnosis and treatment are crucial to improving the prognosis of OSCC-OSF.

Alteration of salivary LPO, MDA, LDH, glutathione, GPx, SOD and vitamins in oral submucous fibrosis: A three-level meta-analysis study

This study aims to investigate the alteration of salivary biomarker profiling in the development of oral submucous fibrosis (OSMF) and to explore the influence of saliva in the diagnosis of OSMF. A systematic search of published articles using the PRISMA guidelines was conducted to identify relevant studies on OSMF and saliva. All eligible studies, including case-control, cross-sectional studies, cohort, and pilot studies, contained the evaluation of salivary biomarker profiling in patients with OSMF. Salivary biomarker data from 28 selected articles were categorized into nine groups, and their mean values were determined. A three-step meta-analysis was performed by grouping salivary biomarker profiling into more heterogeneous categories based on OSMF classification, considering functional, histological, and clinical grading. The salivary biomarker profiling analysis revealed significant alterations in all markers, indicating their efficacy in OSMF diagnosis. Subgroup analyses highlighted significant associations in oxidative stress and protein with increased mean values, particularly emphasizing lipid peroxidase (LPO), malondialdehyde (MDA), and lactate dehydrogenase (LDH). Conversely, decreased mean values were observed in glutathione, glutathione peroxidase (GPx), superoxide dismutase (SOD), and vitamins. Notably, OSMF grading analysis demonstrated a significant difference in weighted effect sizes for histological grading, particularly in stage IV. The study underscores the alteration of specific salivary biomarkers, particularly those associated with LPO, MDA, LDH, glutathione, GPx, SOD, and vitamins, in diagnosing and grading OSMF.

Areca nut-induced oral fibrosis - Reassessing the biology of oral submucous fibrosis

BACKGROUND

Oral submucous fibrosis (OSF) is a pathological condition characterized by excessive tissue healing resulting from physical, chemical, or mechanical trauma. Notably, areca nut consumption significantly contributes to the development of oral fibrosis. The current definition of OSF, recognizing its potential for malignant transformation, necessitates a more comprehensive understanding of its pathophysiology and etiology.

HIGHLIGHTS

Areca nut induces fibrotic pathways by upregulating inflammatory cytokines such as TGF-β and expressing additional cytokines. Moreover, it triggers the conversion of fibroblasts to myofibroblasts, characterized by α-SMA and γSMA expression, resulting in accelerated collagen production. Arecoline, a component of areca nut, has been shown to elevate levels of reactive oxygen species, upregulate the expression of various cytokines, and activate specific signaling pathways (MEK, COX2, PI3K), all contributing to fibrosis. Therefore, we propose redefining OSF as "Areca nut-induced oral fibrosis" (AIOF) to align with current epistemology, emphasizing its distinctive association with areca nut consumption. The refined definition enhances our ability to develop targeted interventions, thus contributing to more effective prevention and treatment strategies for oral submucous fibrosis worldwide.

CONCLUSION

Arecoline plays a crucial role as a mediator in fibrosis development, contributing to extracellular matrix accumulation in OSF. The re-evaluation of OSF as AIOF offers a more accurate representation of the condition. This nuanced perspective is essential for distinguishing AIOF from other forms of oral fibrosis and advancing our understanding of the disease's pathophysiology.

HLA-DQB1 Allele Polymorphism Associated with Oral Submucous Fibrosis in Hunan, China

Methods

44 OSF patients and 44 healthy volunteers were included in this study. To detect the expression frequency of HLA-DQB1 alleles in the two groups and analyze significant allelic subtypes and their relative risk, polymerase chain reaction (PCR) sequence-specific primers were used. Subsequently, based on the identification of differential genes, we compare the gene expression levels of OSF patients and healthy volunteers expressing differential genes by real-time quantitative PCR.

Results

The expression frequency of the HLA-DQB1 ∗05 : 02 allele in the OSF group (36.4%) was significantly higher than in the controls (13.6%), and exposure to the HLA-DQB1 ∗05 : 02 allele was strongly related to OSF (OR (95% CI) = 3.619 (1.257,10.421), Wald χ2 = 5.681, P=0.017). However, there were no significant differences in the allele expression frequencies of DQB1 ∗02 : 01, DQB1 ∗03 : 03, DQB1 ∗05 : 01, DQB1 ∗05 : 03, DQB1 ∗06 : 02, DQB1 ∗06 : 03, and DQB1 ∗06 : 04 in the OSF group compared with the controls (all P > 0.05). Furthermore, the relative expression level of the HLA-DQB1 ∗05 : 02 allele in the OSF group (3.98 ± 3.50) was significantly higher than in controls (0.70 ± 0.41).

Conclusions

There are differences in the HLA-DQB1 allele polymorphisms between the healthy population and patients with oral submucosal fibrosis. Preliminarily, it is suggested that the HLA-DQB1 ∗05 : 02 allele, which has a strong correlation with OSF and great differential expression between patients with OSF and controls, might be a susceptibility gene for OSF in Hunan.

Hematological profile of OSMF patients with increasing severity

Haematological profile of patients with oral sub mucous fibrosis (OSMF) and its correlation with the severity of OSMF is evaluated. The study comprised of sixty participants with clinical diagnoses. They were divided into smaller groups based on the OSMF stage. Sixty age and gender matched healthy controls were chosen among patients presenting for routine hematological examinations and free of systemic illnesses. Assessment of iron, hemoglobin, and red cell indices in all study participants was carried out. It was observed that the values of haematological tests like (Hb (g/dL), PCV, MCV (fl), MCH, MCHC, Iron (mg/dL) and Vitamin B12 (pg/Ml) was greater in normal subjects as compared to OSMF patients. Values were found to decrease further as the severity (staging) of OSMF increased among OSMF patients. The findings were statistically significant showing decrease in the values of different haematological parameters as the stage of OSMF progressed from stage I to stage III.

Antifibrotic Effect of Baicalin on Arecoline Induced Human Oral Fibroblast: An In-Vitro Study

BACKGROUND

Baicalin is a flavonoid obtained from the Chinese herb Scutellaria baicalensis, which has a wide varieties of health benefits and scope to be studied for its therapeutic potential in oral fibrosis.

AIM

The aim of the study was to investigate the antifibrotic effect of a Baicalin in arecoline induced human oral fibroblast in vitro setting.

MATERIAL AND METHODS

Arecoline and ethanolic extracts of Baicalin were commercially purchased from Sigma-Aldrich. Human oral fibroblasts were cultured and characterized with specific fibroblast markers, and cells were stimulated with arecoline. An MTT assay (3-[4, 5-dimethylthiazol-2-yl]-2, 5-diphenyltetrazolium bromide) was executed to determine the half-maximal inhibitory concentration of arecoline and Baicalin. Arecoline-induced cells (25µg/ml) were treated with a non-toxic dose of Baicalin (proliferative dose of 25µg/ml). Cytokine (CCL2, CXCL-8, IL17, IL-beta, and IL-6) and fibrotic marker genes were studied by reverse transcription-polymerase chain reaction (RT-PCR). The inhibitory effect of Baicalin was studied to prove its antifibrotic properties.

RESULTS

Arecoline significantly upregulated all inflammatory and fibrotic markers. On treatment with 25µg/ml of Baicalin, all inflammatory and fibrotic markers were inhibited. Arecoline affects fibroblast morphology, supporting the fact that arecoline is cytotoxic to cells.

CONCLUSION

Baicalin can be used as an antifibrotic herb to treat OSMF.

Plant leads for mitigation of oral submucous fibrosis: Current scenario and future prospect

The aim of this review is to enumerate medicinal plants and their bioactive compounds that may become potential leads in the mitigation of oral submucous fibrosis (OSMF) in the forthcoming future. It is focused on pathophysiology, risk factors, current treatment regimen, potential plant leads, and future therapies for OSMF. Data were extracted from a vast literature survey by using SciFinder, Web of Science, Google Scholar, and PubMed search engines with relevant keywords. Upon literature survey, we found that the phytochemical 'arecoline' present in the areca nut is the main causative agent of OSMF condition. Currently, OSMF is treated by immunomodulatory and anti-inflammatory agents such as corticosteroids, enzymes (hyaluronidase, chymotrypsin, and collagenase), anti-inflammatory mediators (isoxsuprine and pentoxifylline), dietary supplements (vitamins, antioxidants, and micronutrients), and anti-fibrotic cytokines like interferon-gamma that provides short-term symptomatic relief to OSMF patients. However, some plant leads have been proven effective in alleviating symptoms and mitigating OSMF, which ultimately improves the quality of OSMF patients' life. We concluded that plant drugs like lycopene, curcumin, Aloe vera, colchicine, and Glycyrrhiza glabra are effective against OSMF in various in vitro and/or clinical studies and are being used by modern and traditional practitioners.

Enhanced ZEB 1 stromal expression is a marker for epithelial mesenchymal transition in oral submucous fibrosis

Introduction

Oral submucous fibrosis is a progressive oral mucosal condition that is characterized by inflammation and persistent fibrosis. Epithelial Mesenchymal Transition is a crucial molecular event that contributes to tumor progression and fibrosis, with ZEB 1 and its effect on E-cadherin expression being key molecules in the process. Thera are no tissue level studies of these molecules in oral submucous fibrosis.

Objective

To evaluate the immunohistochemical expression of epithelial mesenchymal transition markers E-cadherin and ZEB1 in oral submucous fibrosis.

Methodology

A total of 30 cases of Oral submucous fibrosis (15 Early OSMF and 15 Advanced OSMF) classified based on the histopathological features were included in the study. Immunohistochemistry was done using two markers i.e. E-cadherin and ZEB1. The difference in the expression of E-Cadherin and ZEB1 among histo-pathological grades of OSMF was done by Mann-Whitney U test.

Results

A slight reduction in the E-cadherin expression was noted in Oral submucous fibrosis but marked enhanced expression of ZEB1 was seen in the connective tissue of OSMF.

Conclusion

An increase in intensity and percentage of positivity of ZEB 1 expression in connective tissue was observed in advanced cases as compared to early OSMF. This can be attributed to role of ZEB1 in mediating EMT via transdifferentiation of fibroblast into myofibroblast and thus predispose to fibrosis in OSMF.

Curcumin in the treatment of oral submucous fibrosis: a systematic review and meta-analysis of randomized controlled trials

The objective was to evaluate the efficacy of curcumin in improving mouth opening (MO), burning sensation (BS), and tongue protrusion (TP) symptoms in patients with oral submucous fibrosis (OSF). An electronic search up to November 2022 was conducted in the PubMed, Web of Science, Embase, EBSCO, ProQuest, and Cochrane Library databases to identify studies using curcumin in the treatment of OSF with comparison to control groups (drugs previously proven to be effective for OSF treatment) or placebo. Only randomized controlled trials (RCTs) were considered. RevMan 5.3 software was used for the meta-analysis. Thirteen RCTs met the eligibility criteria and were included in the analysis. The results showed no significant improvement in MO (in millimetres) for curcumin when compared to control at 1 month (P = 0.91), 2 months (P = 0.54), 3 months (P = 0.56), or 6 months (P = 0.17) of treatment. There was no significant difference in BS (assessed using a visual analogue scale) between curcumin and control after 1 month (P = 0.05), 2 months (P = 0.64), 3 months (P = 0.13), or 6 months (P = 0.56) of treatment. Compared with the control groups, treatment with curcumin for 1 month (P = 0.32), 2 months (P = 0.07), and 3 months (P = 0.14) did not significantly improve the TP (in millimetres) of patients. The administration of curcumin, whether topically applied or taken orally, did not confer statistically significant improvements in MO, BS, or TP in comparison to the control treatments, among patients with OSF. The results of this meta-analysis showed that compared to placebo, the application of curcumin for 6 months markedly alleviated BS (P < 0.001). Curcumin treatment in OSF reaches a clinically effective range, but more bioavailability-centred outcomes should be reported. Robust multicentre RCTs are warranted to elucidate the efficacy of curcumin in improving specific outcomes like MO, BS, and TP in patients with this condition. Defining the therapeutic role of this natural compound may provide an effective botanical alternative for managing OSF.

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

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

Comprehensive Assessment of Albumin and Uric Acid Levels in Oral Submucous Fibrosis: A Comparative Case-Control Study Involving Different Risk Groups

Background Oral submucous fibrosis (OSMF) is a premalignant disorder that impacts the oral cavity and pharynx. Major risk factors for OSMF are attributed to the consumption of betel nuts or tobacco. These substances harbor various carcinogens that trigger the production of free radicals and reactive oxygen species. Antioxidants are pivotal in preserving cellular integrity and impeding the oncogenic transformation of body cells. In this context, albumin and uric acid, being primary antioxidants present in body fluids, bestow a defensive effect against this condition. Thus, the present study is designed to elucidate the differential concentration of albumin and uric acid between patient cases and healthy cohorts. Methodology This case-control study was conducted to evaluate the albumin and uric acid levels in individuals diagnosed with OSMF (cases) and compare them with healthy controls for a period of six months. A cohort of 100 individuals was partitioned into four groups, with each group comprising 25 individuals: Group I was made up of healthy individuals; Group II consisted of individuals who chew tobacco and areca nuts but are not affected by OSMF; Group III included individuals who only use tobacco without areca nuts and are afflicted with OSMF; and Group IV comprised individuals who consume a combination of areca nuts and tobacco and are diagnosed with OSMF. Biochemical evaluation was carried out using the BS-380 chemistry autoanalyzer (Mindray, Shenzhen, China), and the quantification of serum albumin and uric acid was performed by the uricase-peroxidase (POD) method with dihydroxybenzene sulfonic acid (DHBS). Results The study cohort of 100 individuals was made up of 70 males and 30 females, with an average age of 42.51 (11.62) years. The comparison of the mean concentration of serum albumin across all groups revealed that healthy controls exhibited the highest serum albumin concentration of 4.284 (0.618), with a statistically significant p-value (0.001) across all groups. A comparison of the mean value of serum uric acid among all groups showed that healthy controls had the highest value of serum uric acid (5.26±1.161), with a considerable p-value (0.001) between all groups. Conclusion The present study concluded that serum biomarkers assessed were high in healthy individuals and consumption of areca nuts, tobacco, and their products was significantly associated with low levels of albumin and uric acid. Therefore, both albumin and uric acid can be used as important biomarkers for uncovering oral premalignant lesions and conditions ahead of time and can also be used in mass screening.

Prevalence of Oral Submucous Fibrosis With Other Oral Potentially Malignant Disorders: A Clinical Retrospective Study

Background  Oral submucous fibrosis (OSMF) is a chronic, progressive, and potentially malignant oral disorder that causes scarring of the oral cavity, pharynx, and upper oesophagus. It is most common in Southeast Asia, but it is also found in other parts of the world. Oral potentially malignant disorders (OPMDs) are a group of oral lesions that have an increased risk of developing into oral cancer. The study aimed to evaluate the prevalence of OSMF associated with other OPMDs. The presence of multiple OPMDs existing in one patient is a significant finding, as it is associated with an elevated risk of developing malignancy. The risk of malignant transformation increases with the number of OPMDs present in a patient; patients with two OPMDs have a three to four times higher risk of developing malignancy than those with a single OPMD. Patients with three or more OPMDs have a 7-10 times higher risk and the risk of malignant transformation depends on the type of OPMD. Materials and methods The study was conducted in the Department of Oral Medicine and Radiology, Saveetha Dental College and Hospitals, Chennai, India, to investigate the prevalence of OSMF with other OPMDs. The study team retrieved 630 case records of patients with OSMF from the electronic database between January 2018 and March 2023. All of the patients in the study had OSMF, as well as other OPMDs such as leukoplakia, candidiasis, actinic cheilitis, dyskeratosis congenita, erythroplakia, lichen planus, sideropenic dysphagia (Plummer-Vinson syndrome), and discoid lupus erythematosus. Both clinical and histopathological examinations confirmed these diagnoses. Oral mucosal lesions without coexisting OSMF were excluded. The study was done on the basis of age group, habits, type of habits, associated coexisting lesions, and systemic condition. Results The patients were clinically examined and diagnosed. Of the 630 cases, 10% had OSMF with OPMDs. The most common OPMDs associated with OSMF were leukoplakia (86%), followed by candidiasis (12%) and both leukoplakia and candidiasis (2%). Based on gender, the incidence of OSMF was higher in males compared to females with 67% and 33%, respectively. Conclusion OSMF is more likely to develop into malignancy; the widespread use of areca nut products in India has contributed to the rising incidence of OSMF. Accumulating epidemiological data can help to identify high-risk populations for prevention and control measures. Earlier oral cancer diagnosis and treatment can increase the likelihood of a favourable outcome.

Evaluation of Platelet Parameters in Oral Submucous Fibrosis and Oral Squamous Cell Carcinoma in a Background of Oral Submucous Fibrosis

CONTEXT

The role of platelet parameters as markers of inflammation in various diseases is now in limelight. The interaction between cancer cells and platelets is a well-established phenomenon. Oral submucous fibrosis (OSMF) is a premalignant disorder with a malignant transformation rate of 2-8%. This study aimed to evaluate platelet parameters in OSMF and oral squamous cell carcinoma (OSCC) in the background of OSMF. This cross-sectional study was performed using secondary data retrieved between January 2019 and December 2019 in the Department of Oral Pathology and the Hematology Laboratory.

METHODS AND MATERIALS

The data retrieved included 44 histopathologically proven OSCC in a background of OSMF (group III) and 36 OSMF (group II). The haematological parameters of these selected cases were retrieved from the Sysmex XN-1000 automated hematology analyser database. A control group (group I) comprises 50 subjects with normal (negative/unflagged) haematological parameters. All data were statistically analysed using SPSS 20.0. The significance level of tests was set at 5%.

RESULTS

The mean platelet volume (MPV) (9.60 [±0.95] P < 0.001), platelet distribution width (PDW) (10.45 [±1.9], P < 0.001), platelet large cell ratio (PLCR) (21.70 [±7.98], P < 0.001), and the ratio of mean platelet volume to total platelet count (MPV/PLT) (0.03 [0.01], P < 0.001) were lower in group III when compared to the other two groups.

CONCLUSIONS

Platelet parameters may be used as indices in the OSCC in the background of OSMF. However, large-scale prospective studies are necessary to evaluate the utility of these parameters during the malignant transformation of OSMF, thereby encouraging prompt treatment to prevent morbidity and mortality.

Comparison of triamcinolone with pentoxifylline and vitamin E efficacy in the treatment of stage 2 and 3 oral submucous fibrosis: A randomized clinical trial

Objective

The objective of this study was to assess the effectiveness of triamcinolone in combination with pentoxifylline and vitamin E in the treatment of patients with level two and three oral submucous fibrosis.

Methods

The study aimed to compare the efficacy of corticosteroid injections (triamcinolone) versus pentoxifylline and vitamin E in the therapy of patients with stage two and three oral submucous fibrosis. A total of 42 participants with indications and features of oral submucous fibrosis were enrolled between January 2020 and September 2021. The patients' age and mouth opening were evaluated, and descriptive statistics and paired t-test were used for analytical investigation.

Results

The study showed a statistically significant improvement in both treatment groups (p = 0.001) concerning pre- and post-treatment deviations. However, when comparing the standard differences in treatment outcomes between the two study groups, only mouth opening exhibited a statistically significant difference (p = 0.001).

Conclusions

The findings indicate that a treatment regimen combining pentoxifylline and triamcinolone can significantly alleviate oral submucous fibrosis symptoms, including mouth opening, pain, and flaring agitation, thereby enhancing the affected individual's quality of life.

Nasolabial Flap in the Management of Oral Sub Mucous Fibrosis: A Series of Cases

The objective of this study was to evaluate the outcomes of the nasolabial flap in the management of oral submucous fibrosis (OSMF). The descriptive case series included 75 patients diagnosed with OSMF who underwent surgical intervention under general anesthesia. Preoperative mouth opening measurements were compared with postoperative measurements taken after 2 months. Regarding mouth opening, out of the 75 patients, 4 (5.3%) had unsatisfactory results after treatment, while 22 (29.3%) experienced satisfactory outcomes. The majority of patients, 49 (65.3%), achieved normal mouth opening (more than 30 mm) following the Nasolabial flap procedure. This indicates that the Nasolabial flap yielded favorable results in terms of restoring normal mouth opening and benefiting the patients. Based on the findings of this study, the Nasolabial flap was determined to be a viable surgical option for managing oral submucous fibrosis due to its ease of operation, reliable flap vascularity, and low post-operative complication rate. The only drawback identified was the presence of a surgical scar, which can be addressed through secondary correction procedures.

Molecular pathways of oral submucous fibrosis and its progression to malignancy

OBJECTIVE

The review aims to comprehend various factors engaged in the alteration of molecular events resulting in Oral submucous fibrosis (OSMF) and its malignant transformation.

DESIGN

Literature pertinent to pathways involved in OSMF were explored in databases such as PubMed, Scopus and Google Scholar. The relevant literature was reviewed and critically appraised in this narrative review.

RESULTS

Areca nut components influence myriad of cellular molecules such as cytokines, growth factors, myofibroblasts, non-coding RNAs and alter their expression. These aberrantly expressed molecules drive the progression of OSMF from localized inflammation to fibrosis of buccal mucosa. The oral tissue suffers from oxidative stress, hypoxia, autophagy, aberration of cell cycle and DNA damage. Apoptosis of epithelial layer results in its atrophy facilitating deeper penetration of areca nut elements. With the advance of disease, epithelial-mesenchymal transition eventuates and promotes dysplasia. The jeopardized expression of various cellular molecules, suppressed apoptosis, along with increased genetic alterations and neovascularization favors the malignant transformation.

CONCLUSION

OSMF is a progressive disorder with complex mechanism of pathogenesis initiated by inflammation of oral mucosa. Continuous habit of areca nut chewing and the resulting insult to the tissues prevents healing process and is destined to debilitating disease which affects the quality of life with a higher probability of progression to malignancy.

Comparative Efficacy of Interventions for the Management of Oral Submucous Fibrosis: A Systematic Review and Network Meta-Analysis

Introduction: Oral submucous fibrosis (OSMF) is a chronic premalignant condition and is characterized by fibroblastic change of lamina propria and stiffness of oral mucosa. Though there are several treatment options available, the best agent is not yet identified. This study assessed the comparative efficacy and safety of medical interventions in the management of OSMF. Methods: A systematic review was performed to identify randomized controlled trials (RCTs) that compared the efficacy of interventions for OSMF with each other, or placebo. A network meta-analysis was performed, and the interventions were ranked according to their efficacy based on the surface under the cumulative ranking. (PROSPERO Registration no: CRD42021255094). Results: Thirty-two RCTs comprising 2063 patients were eligible for quantitative analysis. In terms of therapeutic efficacy in the improvement of mouth opening Oxitard, a herbal formulation was ranked as the most efficacious agent, [MD, 10.29 (95%CI 6.34–14.25)] followed by combination therapy of Lycopene with corticosteroids and hyaluronidase [MD, 7.07 (95%CI 1.82–12.31)]. For improvement of burning sensation aloe vera was ranked first [MD, 6.14 (95%CI 4.58–7.70)] followed by corticosteroids with antioxidants [MD, 6.13 (95%CI 4.12–8.14)] and corticosteroids in combination with hyaluronidase with antioxidants [MD, 5.95 (95%CI 3.79–8.11)]. In terms of safety, most of the drugs were reported to cause mild adverse effects only. Significant inconsistencies could be identified in the analysis for both the outcomes assessed and were further explored. Conclusions: Our study highlighted the potential efficacy of several agents over placebo in the improvement of mouth opening and burning sensation in OSMF patients. However, the RCTs lacked methodological soundness. Well-designed studies with a larger number of participants with a rigorous randomization process and stringent methodology are recommended to strengthen the results obtained, which may help to construct a clinical guideline for OSMF management.

Oral Potentially Malignant Disorders: Etiology, Pathogenesis, and Transformation Into Oral Cancer

Among oral diseases, oral cancer is a critical health issue due to its life-threatening potential. Globocan, in its 2020 report, estimated ∼0.37 million new cases of oral cancer, with the majority of them coming from the Asian continent. The WHO has anticipated a rise in the incidences of oral cancer in the coming decades. Various factors, such as genetic, epigenetic, microbial, habitual, and lifestyle factors, are closely associated with oral cancer occurrence and progression. Oral lesions, inherited genetic mutations (dyskeratosis congenital syndrome), and viral infections (HPV) are early signs of oral cancer. Lesions with dysplastic features have been categorized under oral potentially malignant disorders (OPMDs), such as oral leukoplakia, erythroplakia, oral submucous fibrosis (OSMF), and proliferative verrucous leukoplakia, are assumed to have a high risk of malignancy. The incidence and prevalence of OPMDs are recorded as being high in South-Asian countries. Early detection, prevention, and treatment of OPMDs are needed to prevent its malignant transformation into oral cancer. Many advanced diagnostic techniques are used to predict their progression and to assess the risk of malignant transformation. This communication provides insight into the importance of early detection and prevention of OPMDs.

Efficacy of spirulina in management of oral submucous fibrosis − a systematic review

Objective: The aim of this systematic review was to evaluate the efficacy of spirulina in the management of oral submucous fibrosis. Methodology: Databases (MEDLINE via PubMed, Cochrane, EBSCO-host, Scopus, Science Direct, Clinical Trial Registry- India (CTRI) and Google scholar), review articles, bibliographies and related journal were searched from 1st January 2010 to 30th May 2020, using various combinations of MeSH terms and keywords. Results: A total of 5 clinical trials were analysed for the review, of which 4 were randomized controlled trials and 1 was non-randomized controlled trial. Mouth opening and burning sensation were analysed as primary outcome in all 5 studies. For both outcomes some studies reported statistically significant difference whereas others showed non-significant results on comparing with different interventions. Also, high risk of bias was observed among studies after performing quality analysis. Conclusion: Although the studies suggest efficacy of spirulina in management of OSF, but due to the high risk of bias there is a weak evidence regarding the effectiveness of spirulina in treating OSF. So, more uniform and standard trials on larger population should be carried out.

Correlation of Clinical Features in Oral Submucous Fibrosis: A 9-Year Retrospective Study

BACKGROUND

Oral Submucous Fibrosis is a chronic debilitating disease and potentially malignant disorder of the oral cavity known in medical literature for a long time. The study aims to correlate the clinical staging of Oral Submucous Fibrosis with various clinical findings of the oral mucosa like hyperpigmentation, erosions, ulcerations, VAS score, tongue protrusion, and cheek flexibility.

METHODS

A retrospective observational study was undertaken and records of 1267 clinically diagnosed cases of OSMF were included in the study. Clinical grading was done as per criteria by Lai DR et al. The observations were tabulated and subjected to statistical analysis using SPSS software.

RESULTS

In our study, the incidence of hyperpigmentation, erosions, and ulcerations was higher in Group C OSMF. Visual analog scores in the range of 5-6 was noted in 40.9% of the total subjects, out of which 36.2% belonged to Group C OSMF. Tongue protrusion of less than 25 mm was seen in 10.65% of the subjects. Cheek flexibility of less than 0.6 cm was seen in 19.62% of the subjects, most of which belonged to Group D.

CONCLUSION

In our study, we found an increase in the occurrence and severity of symptoms with an increase in grades of OSMF, but this increase was not observed to be consistent. Hence classification based on a single clinical entity cannot be sufficient and correlations to other clinical findings should be studied over a large population and a multi-tier classification could be proposed in the future.

Knockdown of LncRNA NEAT1 inhibits myofibroblast activity in oral submucous fibrosis through miR-760/TPM1 axis

Background/purpose

Oral submucous fibrosis (OSF) is a fibrotic disease with high transformation of malignant disorders. Aberrant expression of lncRNA nuclear enriched abundant transcript 1 (NEAT1) was engaged with various fibrosis models, but its mechanism in OSF remained elusive.

Materials and methods

Fibrous buccal mucosa fibroblasts (fBMFs) were from OSF specimens. Myofibroblast activities including the alpha smooth muscle actin (α-SMA) distribution and invasion capacities were determined by Immunocytochemistry and Transwell assays. Gene and protein were identified by quantitative real time polymerase chain reaction or western blotting. Binding relationship was analyzed via Starbase and dual-luciferase reporter or RNA immunoprecipitation assays.

Results

NEAT1 and Tropomyosin-1 (TPM1) were significantly increased in OSF specimens, but miR-760 was decreased. NEAT1 knockdown repressed myofibroblast activities and reduced the fibrosis and Wnt/β-catenin pathway via miR-760/TPM1 axis. MiR-760 inhibition could reverse the regulation of NEAT1 knockdown via TPM1 in fBMFs.

Conclusion

NEAT1 knockdown inhibited myofibroblast activities and Wnt/β-catenin pathway via miR-760/TPM1 axis in fBMFs. NEAT1 could be the target for inhibiting myofibroblast activities in fBMFs for OSF treatment.

Arecoline Enhances Phosphodiesterase 4A Activity to Promote Transforming Growth Factor-β-Induced Buccal Mucosal Fibroblast Activation via cAMP-Epac1 Signaling Pathway

Chewing areca nut (betel quid) is strongly associated with oral submucous fibrosis (OSF), a pre-cancerous lesion. Among the areca alkaloids, arecoline is the main agent responsible for fibroblast proliferation; however, the specific molecular mechanism of arecoline affecting the OSF remains unclear. The present study revealed that arecoline treatment significantly enhanced Transforming growth factor-β (TGF-β)-induced buccal mucosal fibroblast (BMF) activation and fibrotic changes. Arecoline interacts with phosphodiesterase 4A (PDE4A) to exert its effects through modulating PDE4A activity but not PDE4A expression. PDE4A silence reversed the effects of arecoline on TGF-β-induced BMFs activation and fibrotic changes. Moreover, the exchange protein directly activated by cAMP 1 (Epac1)-selective Cyclic adenosine 3′,5′-monophosphate (cAMP) analog (8-Me-cAMP) but not the protein kinase A (PKA)-selective cAMP analog (N6-cAMP) remarkably suppressed α-smooth muscle actin(α-SMA) and Collagen Type I Alpha 1 Chain (Col1A1) protein levels in response to TGF-β1 and arecoline co-treatment, indicating that cAMP-Epac1 but not cAMP-PKA signaling is involved in arecoline functions on TGF-β1-induced BMFs activation. In conclusion, arecoline promotes TGF-β1-induced BMFs activation through enhancing PDE4A activity and the cAMP-Epac1 signaling pathway during OSF. This novel mechanism might provide more powerful strategies for OSF treatment, requiring further in vivo and clinical investigation.

Laser as a promising non-invasive technique to treat oral submucous fibrosis: A systematic review of the literature

Background

Oral submucous fibrosis (OSMF) is one of the common oral potentially malignant disorders that can result in severe morbidity. Depending upon the stage of disease, multiple management therapies exist which include medicinal and surgical approaches. Although the surgical approach is preferred in severe conditions, numerous studies have reported its post-surgical deteriorating outcomes including increased fibrotic changes. To reduce these post-surgical complications, Light amplification by stimulated emission of radiation (Laser) has been introduced and studied as a non-invasive technique to treat oral submucous fibrosis. However, there exists a lack of knowledge about ‘which laser shows a better post-treatment outcome’. Accordingly, this review aims to answer this question.

Materials and methods

A systematic review of the published literature was performed using an electronic search in PubMed/Medline, Science Direct, Web of Science, Embase, J- STAGE, Google Scholar, and Scopus databases, from 1952 till 2019 using keywords like, ‘Oral submucous fibrosis’, ‘Treatment’, ‘Laser’, ‘Trismus’, ‘ Fibrosis’, ‘Surgical’, ‘Non-invasive’, and ‘Postoperative results’.

Results

The search strategy revealed 20 relevant published studies in which laser had been used to treat 250 patients of OSMF. Effective results were found without any complications in all the cases after follow up.

Conclusion

Observing the current literature, it can be concluded that laser might be used as a potential non-invasive approach in the management of OSMF, however, large scale studies are required to investigate the efficacy and other effects of this technology.

Long Non-Coding RNAs in Oral Submucous Fibrosis: Their Functional Mechanisms and Recent Research Progress

Many studies have shown that most genomes are transcribed into non-coding RNAs (ncRNAs), including microRNAs (miRs) and long non-coding RNAs (lncRNAs), which can affect different cell characteristics. LncRNAs are long heterologous RNAs that regulate gene expression and various signaling pathways during homeostasis and development. Studies have shown that a lncRNA is an important regulatory molecule that can be targeted to change the physiology and function of cells. Expression or dysfunction of lncRNAs is closely related to various genetic, autoimmune, and metabolic diseases. The importance of ncRNAs in oral submucosal fibrosis (OSF) has garnered much attention in recent years. However, most research has focused on miRs. The role of these molecules in OSF is incompletely understood. This review focuses on the emerging role and function of lncRNAs in OSF as novel regulators. Finally, the potential functional role of lncRNAs as biomarkers for OSF diagnosis is also described. LncRNAs are expected to become a new therapeutic target, but more research is needed to understand their biological functions more deeply.

Immunopathogenesis of oral submucous fibrosis by chewing the areca nut

Oral submucous fibrosis (OSF) is a chronic, progressive, scarring, and premalignant disease of the oral mucosa. Its pathogenic factors are complex and include chewing areca nuts or other spicy food items, nutrition, and genetic and immune factors. Recently, immune factors have become the focus of medical research, with increased attention being paid to the role of immune regulation in diseases, particularly tumors. OSF is accompanied by obvious changes in the immune microenvironment. The aim of this review is to discuss the potential relationship of OSF and areca nuts genetic with the immune system, including lymphocytes, macrophage, Langerhans cell, mast cell, and substances released by activated immune cells, to determine the pathogenesis and treatment of OSF from an immunologic viewpoint.

Oral submucous fibrosis: An overview of a challenging entity

The oral cavity is considered to be a mirror of the body's health, as it reflects the manifestations of various systemic disorders. Most of the oral mucosa is derived embryologically from an invagination of ectoderm and thus, like other similar orifices, it may become involved in the disorders that are primarily associated with the skin. Oral submucous fibrosis is one of the commonest precancerous conditions of the oral mucosa involving any part of the oral cavity resulting in tissue scarring, dysphagia and trismus. It is a collagen-related disorder characterized by excessive fibrosis in the oral submucosa, hyalinization and degenerative changes in the muscles. This disease has become a challenging entity for dermatologists due to resemblance of its features to various mucocutaneous conditions. An improper diagnosis can lead to wrong treatment and additional complications. Dermatologists need to be aware of the characteristic features of this disease which can distinguish it from other similar conditions. This review aims to focus on the detailed aspects of oral submucous fibrosis including its historical background, etiological factors, pathogenesis, clinical features, differential diagnosis, investigations, management and future perspectives.

Research Achievements of Oral Submucous Fibrosis: Progress and Prospect

Oral submucous fibrosis (OSMF) is a kind of chronic, insidious disease, and it is categorized into potentially malignant disorders (PMD), which poses a global and regional problem to public health. It is considered to be a multifactorial disease, such as due to areca nut chewing, trace element disorders, and genetic susceptibility. However, there is still no unanimous conclusion on its pathogenesis, diagnosis, and treatment strategies. Hence, this article provides a comprehensive review and prospect of OSMF research, providing scholars and clinicians with a better perspective and new ideas for the research and treatment of OSMF.

Biochemical status of serum iron in histopathological grades of oral submucous fibrosis

Background

Oral submucous fibrosis is a multifactorial, chronic disease of oral mucosa characterized by mucosal atrophy and fibrosis leading to functional morbidity; amongst many iron deficiency is considered as one of the risk factor. Also the iron level is considered to be depleted due to increased utilization during collagen synthesis. This study was conducted to evaluate the level of iron in patients with fibrosis and correlate with different histopathological grades.

Methods

A total of 40 clinically diagnosed and histopathologically confirmed cases of submucous fibrosis were considered. Clinical data were recorded and status of iron was estimated through serum iron and total iron binding capacity by ferrozine method using a digital auto-analyzer. The level of iron was correlated with the histopathological grades and epithelial dysplasia.

Result

The mean age of patients was 37.07 ± 14.63 years with the male to female ratio of 6.5:1. Areca nut consumption was associated with all the cases among which 87.5% of cases were exposed to commercial forms. 37.5% of cases were in early grade whereas 60% in moderately advanced histopathological grade. The level of mean serum iron and total iron binding capacity was higher in moderately advanced than in early grade. However no statistically significant difference was observed within the histopathological grades.

Conclusion

Iron is influenced by many factors like dietary intake, food habits, metabolic reactions, chronic diseases, etc. Serum iron is reduced in patients with oral submucous fibrosis which should be supplemented to impede the carcinogenic potential and improve the treatment outcome.

Medicinal management of oral submucous fibrosis in the past decade- A systematic review

INTRODUCTION

Oral submucous fibrosis (OSMF) is a potentially malignant disorder with a high rate of malignant transformation. It is associated with chewing of areca nut and tobacco products with a high global prevalence, particularly in the southeast Asian countries. A wide range of treatment modalities are available, ranging from corticosteroids, antioxidants, nutritional supplements to herbal medicines but lacks a reliable treatment regimen.

AIM

This systematic review will comprehensively analyze the medicinal treatment for OSMF from 2011 to 2020, apprise the literature with new clinical studies, and initiate a discussion about other potential medicines.

MATERIAL AND METHODS

A comprehensive electronic search was conducted in Pubmed, Scopus, and other databases from January 2011 to June 2020 according to the PRISMA guidelines, to identify all the clinical studies for the medicinal management of OSMF with definite keywords and defined criteria.

RESULTS

Among the thirty-two included clinical studies 23 were randomized controlled studies and 9 were case-control studies. The treatment outcomes were diverse, and the majority of the studies showed improvement in the subjective signs and symptoms of OSMF. Only a few studies noticed the side effects.

CONCLUSION

No single treatment modality is effective in the management of OSMF. The concurrent use of triple therapy is efficacious. The naturally occurring herbal medicines have an immense potential in the management of OSMF. Therefore, high-quality, longitudinal, multi-center randomized controlled trials with larger samples need to be conducted to further assess the efficacy of various medicinal formulations in conjunction with physiotherapy in the management of OSMF.

Efficacy of lycopene in management of Oral Submucous Fibrosis- A systematic review and meta-analysis

Purpose

To evaluate the efficacy of lycopene in the management of Oral Submucous Fibrosis (OSMF).

Study design

A comprehensive search was done in MEDLINE via PubMed, Cochrane, EBSCO-host and Google scholar from July 31st^, 1999 to July 31st^, 2019 to identify OSMF related clinical trials (Randomized and Non-randomized) involving lycopene as one of the intervention.

Results

16 randomized control trials and 3 non-randomized control trials comprising 1181 subjects were included. The results of meta-analysis showed non-significant differences between lycopene and other interventions used in the treatment of OSMF.

Conclusion

The present review suggests that lycopene is a safe and equally effective therapeutic modality as compared to other interventions for patients with OSMF. Further well-designed clinical trials are required to accurately assess the effectiveness of lycopene as compared to other medicinal treatments in the management of OSMF.

Evaluation of serum immunoglobulin (IgG, IgM, IgA) in potentially malignant disorders of oral cavity - A case control study

Background

Only few studies have been done to evaluate level of serum immunoglobulins (IgG,IgM,IgA) in patients with Potentially Malignant Disorders (PMD) like Leukoplakia, Oral Submucous Fibrosis (OSMF) and Oral Lichen Planus (OLP) as tumour markers.

Aims and objectives

To estimate the serum immunoglobulins level (IgG, IgM, IgA) in leukoplakia, OSMF and oral lichen planus (OLP) patients and its comparison with levels among control groups and Weather these values can be used to predict severity of disease or not.

Materials and methods

30 patients with different potentially malignant disorders like leukoplakia, OSMF and oral lichen planus and 30 healthy controls were selected at random and subjected for analysis of serum IgG, IgA, IgM. Statistical methods employed were mean, standard deviation and ANOVA test.

Results

We observed significant elevated levels of all the immunoglobulins in leukoplakia, OSMF and oral lichen planus when compared with the control group and levels were increasing with clinical stages of OSMF (p < 0.05).

Conclusions

All these immunoglobulins are indicative of tumour burden or transformation of malignancy in higher stage and might be employed as prognostic indicators in these disorders.

Evaluation of Hematological profile in Oral Submucous Fibrosis: A Cross-sectional Study

AIMS

The purpose of this study was to estimate hemoglobin (Hb) level, red cell indices (RCIs), serum iron level and Vitamin B12 level in patients with oral submucous fibrosis (OSMF) and to analyze the association of these parameters in different stages of OSMF.

SETTING AND DESIGN

This case-control study comprised of 65 individuals, with 40 OSMF patients and 25 controls. The OSMF patients were graded clinically according to the classification by Arakeri et al. Fasting blood samples were collected from both groups for hematological evaluation.

STATISTICAL ANALYSIS USED

The mean values and standard deviations were calculated by Chi-square test. Normality of various parameters was evaluated by Kolmogorov-Smirnov test. The independent t-test was used to compare more than two means simultaneously. Correlation analysis was done by Karl Pearson's correlation coefficient method.

RESULTS

The OSMF patients were in the age range of 21-67 years, with a mean age of 39.85 ± 10.42 years. The mean value of Hb of the control group was 14.24 ± 1.03 g/dL, whereas that of OSMF group was 11.18 ± 2.06 g/dL (P < 0.001). The mean value of the serum iron level of the control group was 119.67 ± 42.42 μg/dL, whereas that of the OSMF group was 45.04 ± 10.41 μg/dL (P < 0.001). The mean value of serum Vitamin B12 levels of the control group was 422.98 ± 112.57 μg/dL, whereas that of the OSMF group was 211.78 ± 45.17 μg/dL (P < 0.001). The RCIs including packed cell volume, mean corpuscular volume, mean corpuscular Hb (MCH) and MCH concentration were significantly reduced in OSMF cases. Iron deficiency was present in 38 patients among the study group and Vitamin B12 deficiency was present in 22 patients of the study group.

CONCLUSION

OSMF causes depletion of minerals and trace elements, and its replenishment is required for the healing of tissues and performing daily routine activities.

Evaluation of mast cells and burning sensation in various stages of Oral Submucous Fibrosis

Background

Oral Submucous Fibrosis (OSMF) is a potentially malignant disorder and burning sensation is the initial complaint among these patients. Scientific literature has established that mast cells play a major role in various inflammatory disorders. However, OSMF being an inflammatory disorder, the role of mast cells is yet to be established. Hence the aim of this study was to evaluate mast cells and burning sensation in various stages of Oral Submucous Fibrosis.

Methods

The study population comprised of forty subjects, thirty were clinically confirmed cases of OSMF and ten healthy individuals served as control. A complete history and clinical examination followed by an incisional biopsy was performed. Samples obtained were subjected to routine histopathological examination and mast cells evaluation.

Results

Mean number of total mast cells in Stage I, II and III OSMF were 8.5 ± 0.7, 11.31 ± 8.8 and 24.7 ± 21.2 respectively. There was a significant difference in total mast cell count between cases and controls. Degranulated mast cells was a significant predictor (p = 0.028), indicating role in clinical staging of OSMF. Degranulated mast cells had a significant role and was a positive predictor (B = 0.763, OR 2.145[95%CI 1.055-4.630]) at moderate levels of burning sensation. A significant difference (p = 0.029) in burning sensation across histopathological grades was also observed in the study.

Conclusion

Degranulated mast cells were found to have a significant influence in mild to moderate levels of burning sensation among OSMF patients. Role of degranulated mast cells were also found to be significant in various clinical stages of OSMF.

Causal inference and directed acyclic graph: An epidemiological concept much needed for oral submucous fibrosis

Oral submucous fibrosis (OSMF), although already established as an oral potentially malignant disorder (OPMD), still stands over a weak bridge because of its controversial pathogenesis. There has been tremendous work on this disease since 1962, surprisingly, we are unsuccessful in finding the exact causation of OSMF. The potential cause for this is either a lack of systematically performed clinical observational studies or over-interpreted inferences of the presented results. Accordingly, the literature is piled with complex data that is being followed by emerging researchers. Hence, this conceptual paper is presented to focus and explain only the epidemiological concepts of causal inference and the construction of DAGs. These concepts will help to encode our subject matter knowledge and assumptions regarding the causal structure problem, classify the source of systematic bias, identify the potential confounders, potential issues in the study design, and guide the data analysis.

Herbal derivatives in the management of mouth opening in oral submucous fibrosis-A network meta-analysis

OBJECTIVES

Oral submucous fibrosis is a potentially malignant disorder commonly seen in Asian countries. In this disease, the mucosa becomes stiff and patients have difficulty in mouth opening, thus affecting their quality of life. Recently, practitioners are focusing on herbal derivatives instead of commonly practiced intralesional steroids for the management of this disorder. Hence, we conducted a network meta-analysis of randomized clinical trials on herbal derivatives to identify the most effective treatment for oral submucous fibrosis.

MATERIALS AND METHODS

Electronic search for articles published in various journals was undertaken through various search engines till January 2020. 14 articles were selected which had performed randomized control trials of herbal derivatives against control/placebo. Frequentist network meta-analysis was performed using R studio software, and effective treatment ranking was derived.

RESULTS

The treatment ranking was generated, and relative to mouth opening, the most effective treatment was lycopene administered along with vitamin E and the second effective drug was aloe vera gel.

CONCLUSION

This network meta-analysis highlights the efficacy of some of the drugs of herbal origin which can be implemented by the practitioners in the management of initial stages of oral submucous fibrosis.

Clinical efficacy of mouth exercising devices in oral submucous fibrosis: A systematic review

Background

The management of oral submucous fibrosis (OSF) is primarily focused towards minimizing patient's symptoms and to prevent cancer development. Mouth exercise physiotherapy independently or in combination with other modalities is considered to be a mainstay for increasing the mouth opening (MO). The present systematic review was performed to identify different mouth exercising devices (MEDs) used and to provide detailed information on the fabrication and clinical efficacy of these devices among OSF patients.

Methods

PubMed, Scopus, Web of Science, Google Scholar and CINAHL were searched for relevant literature until February 2019 and the information was extracted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. All full text papers describing use of MED in OSF patients were considered eligible.

Results

Initial search resulted in 88 hits. After removing duplicates and screening of titles and abstracts, five papers that met the inclusion criteria were included. We identified five MEDs used for increasing the MO in OSF patients. Only one study administered additional treatment with topical steroids, oral antioxidants and ice-cream stick regime. The follow-up across studies ranged from 8 weeks to 6 months. Majority of the studies reported significant improvement in the MO without any relapse and side effects.

Conclusions

MED could play an important role in the management of OSF. Limited researches in this area suggest a dire need for the further investigations using randomized controlled trials.

Photobiomodulation therapy inhibits oral submucous fibrosis in mice

Objectives

Oral submucous fibrosis (OSMF) is a chronic inflammatory disease and a potentially malignant oral disorder. However, the best therapeutic treatment for OSMF remains uncertain. Our previous study showed that photobiomodulation (PBM) therapy and forskolin could reduce arecoline‐induced fibrosis reactions via the cAMP pathway. The present study aimed to establish an animal model of areca nut extract (ANE)‐induced OSMF and to evaluate the therapeutic potential of PBM and forskolin for ANE‐induced OSMF.

Subjects and methods

The mice were divided into five groups. The buccal tissues were harvested for histomorphological analysis and immunoblotting.

Results

Our results showed that PBM significantly reduced the development of ANE‐induced OSMF, quantified by changes in submucosal layer thickness and collagen deposition. Additionally, PBM could extensively reduce the protein expression of the fibrotic marker genes alpha‐smooth muscle actin (α‐SMA) and connective tissue growth factor (CTGF) in buccal submucous lesions. However, forskolin treatment significantly decreased the protein expression of fibrotic marker genes but slightly decreased the observed histomorphological changes.

Conclusions

We established an ANE‐induced OSMF mouse model, which also provided a model for the development of a therapeutic treatment for OSMF. The anti‐fibrotic effects of PBM and forskolin may be useful for clinical interventions.

Oral submucous fibrosis in children and adolescents: Analysis of 36 cases

Oral submucous fibrosis (OSMF) is a chronic debilitating irreversible oral potentially malignant disorder affecting any part of the oral cavity. It is usually seen in adults but rarely noticed in children and adolescents. Since the paucity of the cases, there exists a gap of knowledge in the causative habits, root reasons of habit initiation, age of habit initiation, and the common clinical representation of this disorder. The current article aims to bridge this gap by presenting unusual 36 cases of children and adolescents reported at the tertiary care hospital of Vadodara, Gujarat, India, with specific areca nut chewing habit and distinct features of OSMF. Furthermore, the present case series is the first of its kind in the scientific literature with a high number of OSMF cases in children and adolescents.

Oral submucous fibrosis: a contemporary narrative review with a proposed inter-professional approach for an early diagnosis and clinical management

Oral Submucous fibrosis (OSMF) has traditionally been described as "a chronic, insidious, scarring disease of the oral cavity, often with involvement of the pharynx and the upper esophagus". Millions of individuals are affected, especially in South and South East Asian countries. The main risk factor is areca nut chewing. Due to its high morbidity and high malignant transformation rate, constant efforts have been made to develop effective management. Despite this, there have been no significant improvements in prognosis for decades. This expert opinion paper updates the literature and provides a critique of diagnostic and therapeutic pitfalls common in developing countries and of deficiencies in management. An inter-professional model is proposed to avoid these pitfalls and to reduce these deficiencies.

Reasons for Initiation of Areca Nut and Related Products in Patients with Oral Submucous Fibrosis within an Endemic Area in Gujarat, India

Background: While the patterns of consumption of areca nut and its by-products (ANBP) vary across South Asia and the rest of the world, all users share the probable severe outcome of oral submucous fibrosis (OSMF), and this is well reported. The role of psychosocial drivers of habit initiation and addiction is reported less. Objective: To reveal the burden of ANBP abuse, exploring the psychosocial relationship between sex, age at first exposure (AFE), the reason for initiation (RFI) with the type of habit (TOH). Methodology: Data came from the prospective hospital-based study conducted at K.M. Shah Dental College and Hospital covering years 2017 and 2018. Patients with oral lesions were assessed with complete history recording demographics, TOH, AFE, RFI, duration of habit, and clinical diagnosis of any oral and systemic diseases. Patients with a history of scleroderma, facial burns, and oral malignancy were excluded. Results: Of the 13,874 patients, 9.89% reported ANBP. We included 1000 OSMF patients. The mean age of the study cohort was 38.97 ± 14.29 years, with a range of 17-75 years. Males constituted the majority (80.1%). The most common TOH reported was regular use of gutkha (60.1%) followed by mawa (31.4%) with tension and stress (30.3%) being the most common RFI among the cohort. TOH was notably different in relation to AFE. Interestingly, mawa chewing (38.69%) was observed more in females. Importance: This study reveals the burden of ANBP abuse and reports the complex psychosocial relationships between sex, AFE, and RFI with TOH in OSMF patients in this high incidence population.