Burning sensation in oral submucous fibrosis and its possible association with mucin secreted by affected minor salivary glands

Relationship of Clinical Features with Candidal Carriage in Oral Submucous Fibrosis Patients: A Case-control Study

Background and Objectives:

Oral submucous fibrosis (OSF) is extensively prevalent in India and South-East Asia owing to the habit of arecanut (AN) use. Epithelial atrophy, hyposalivation, and immune alterations in OSF may predispose to increased Candidal carriage. Stomatopyrosis in OSF can result from multiple causes, which may also include Candidal infection. Hence, this study is aimed to assess Candidal carriage, species characterization, salivary flow rate (SFR) and its relationship with the clinical features (stomatopyrosis and mouth opening [MO]) in OSF patients alongwith the response to antifungal treatment in patients with higher Candidal carriage.

Methodology:

In this case-control study, 60 OSF patients and 30 age- and sex-matched control subjects were enrolled. SFR was assessed using modified Schirmer test. Samples for Candidal assessment were collected with the oral rinse technique and cultured. The isolated yeast species were counted and identified based on Gram staining, germ tube test, and CHROMagar. Data were analyzed with Chi-square test, Pearson's correlation test, and one-way ANOVA test.

Results:

The distribution of mean visual analog scale (VAS) score, SFR and MO was significantly varied (P < 0.001) in the study and control groups. Candida was found to be present significantly (P = 0.048) in OSF group as compared to control group. Candida albicans was the predominant species. No statistically significant association was obtained regarding Candidal isolation and SFR, burning sensation and MO in OSF patients. Only 1 patient in the study group yielded a high Candidal carriage (>400 CFU/mL) and reported relief in burning sensation (VAS score) with antifungal therapy.

Conclusions:

OSF patients yielded a significant higher oral Candidal carriage. Although it was not found to be associated directly, its role as a “cause and effect” in SFR and clinical features (stomatopyrosis and MO) of OSF cannot be ignored.

A novel histological grading system for minor salivary gland involvement in oral submucous fibrosis patients with clinico-pathological validation

BACKGROUND

The involvement of minor salivary glands (MSGs) with fibrosis in oral submucous fibrosis (OSMF) pathology is a quite conceivable fact. However, very little attention has been given to the status of MSGs in OSMF.

METHODOLOGY

Total 53 cases of OSMF were recruited and demographic details, mouth opening, clinical oral dryness score (CODS), and buccal mucosal MSG flow rate were determined. The fibrosis around MSGs is categorized into three grades and compared with relevant clinicopathological parameters.

RESULTS

Out of total 53 OSMF patients, there were 15 patients in grade I MSG involvement with fibrosis followed by 24 and 14 patients in grade II and grade III, respectively. Grade I MSG involvement showed maximum mouth opening (32 ± 3.87 mm) followed by Grade II (19.85 ± 4.31mm) and Grade III (11.42 ± 5.21mm) and the differences between them were statistically significant. The CODS score was more in grade III (5.5 ± 1.09 mm) as compared to Grade II (4.04 ± 0.62 mm) and Grade I (2.46 ± 0.74 mm) involvement of MSG. The flow rate was more in grade I (8.02 ± 2.99 mm) as compared to Grade II (3.97 ± 1.09 mm) and Grade III (3.4 ± 0.87 mm) involvement of MSG.

CONCLUSION

The fibrosis associated with OSMF can affect the MSGs located at mucosal and sub-mucosal levels. The clinical determinants such as mouth opening, salivary flow rate, and CODS corroborate with the grading of the degree of MSG involvement with fibrosis.

Proliferative ability and accumulation of cancer stem cells in oral submucous fibrosis epithelium

OBJECTIVES

The driving force of the malignant transformation of epithelial cells during oral submucous fibrosis (OSF) is an unsettled debate. We hypothesized that the expression and accumulation of cancer stem cells (CSCs) are accompanied by epithelial atrophy in OSF.

MATERIALS AND METHODS

The expression levels of Ki67 (proliferation marker), SOX2, and Bmi1 (CSC marker) in the epithelium during the early, middle, and late stages of OSF were measured by immunohistochemistry. At the same time, we focused on the expression of three proteins in OSF patients with benign hyperkeratosis and epithelial dysplasia.

RESULTS

The clinical cohort study showed upregulated expression of the proliferation-associated protein Ki67 in atrophic epithelium in patients with OSF. The expression levels of SOX2 and Bmi1 showed an increasing trend in the progression of OSF. Ki67, SOX2, and Bmi1 were highly expressed in OSF tissues with dysplasia. Moreover, the three proteins were located at the epithelial and mesenchymal junctions, and their expression showed a positive correlation with each other.

CONCLUSION

The results suggest that CSC accumulation could be accompanied by epithelial atrophy during OSF, which may be responsible for the driving forces for OSF carcinogenesis.

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.

Localized peripheral autonomous neuropathy and dysfunctional myoepithelial cells: A novel hypothesis for xerostomia in oral submucous fibrosis

Oral submucous fibrosis (OSMF) is a potentially malignant disorder of the oral cavity characterized by submucosal deposition of dense collagen bundles leading to limited mouth opening. Besides, patients also complain about the burning sensation in the oral cavity and xerostomia. These symptoms have a major impact on the functional and psychological domains of oral health-related quality of life. However, the pathogenesis of xerostomia in OSMF is not yet well established. In our routine histopathology practice, we observed fibrosis surrounding minor salivary glands, distended acini, obliteration of acinar lumen and loss of interstitial spaces. Based on these features, we hypothesized that fibrosis in OSMF drives localized peripheral autonomous neuropathy in minor salivary glands, which leads to dysfunctional myoepithelial cells. These dysfunctional myoepithelial cells will unable to contract and expel saliva out of the salivary secretary unit, thus leading to xerostomia. In the present paper, experiments are recommended to prove this hypothesis, which can be exploited in the future for the development of appropriate drugs.

Expression of cyclooxygenase 2 in oral submucous fibrosis: An immunohistochemical pilot study

Introduction

Oral submucous fibrosis (OSF) is associated with inflammatory changes in at least some stages of the disease. Prostaglandin is one of the main inflammatory mediators and its production is controlled by various enzymes such as cyclooxygenase (COX). The genetic and pharmacological data strongly indicate that COX-2 should be investigated as a potential target for the prevention and treatment of OSF.

Methodology

The study group comprised histologically confirmed specimens (n = 10 each) of early OSF, moderate OSF, advanced OSF and normal oral mucosa for comparison. Immunohistochemistry was performed with avidin-biotin technique and evaluated with scoring methods.

Results

The difference in percentage of expression in normal tissue and OSF was statistically highly significant (P < 0.001). Positive COX-2 exhibited cytoplasmic staining. One-way analysis of variances test was performed to evaluate COX-2 expression in different grades of OSF. Cytoplasmic staining assessed in terms of intensity, percentage of expression and Q Score did not show any statistical difference (percentage of expression F = 0.029, P = 0.971; Q Score F = 0.154, P = 0.858).

Conclusions

Our study indicates that COX-2 may be an important marker of disease progression and might be a reliable prognostic indicator.

New Directions for Oral Submucous Fibrosis Research: Whole Evaluation for Holistic Rehabilitation!

Oral submucous fibrosis (OSF) is an oral potentially malignant disorder (OPMD) associated with prolonged betel-quid (BQ) use. It affects both physiological and psychological dimensions, leading to a significant morbidity. Some challenges in OSF research include: Assessment and correction of: (i) Quality of life, (ii) burning sensation, and (iii) nutritional deficiency. There are numerous medical treatments for OSF, but most of them fail to offer complete rehabilitation. This is because some underpinnings of this condition like "mental factors" that contribute to habit continuation at root level, "poor quality of life," and "nutritional deficiencies" are still uncorrected. We believe that OSF must be managed at the "mind and body" level to accomplish holistic rehabilitation. Herein, we briefly describe the general condition of OSF patients, and highlight the possibility of a novel telomere-based assessment of psychosocial stress, and support use of meditation to counter excessive "telomere shortening" which is linked to oral cancer. We also expand the current view on "burning sensation" in OSF from an entire physical concept to a possibility of mental factors, and finally recommend rich, micronutrient supplementation (through diet) to counter free radical production within the hypoxic oral epithelium.

"Introducing Modified Dakkak and Bennett Grading System for Indian Food in Oral Submucous Fibrosis": A Dharwad Study

Oral submucous fibrosis (OSMF) is one of the "diseases of civilization" because of the large differences in prevalence among races, geographic areas, and individuals at different socioeconomic levels. It is a premalignant condition strongly associated with the habit of chewing areca nuts. This study is to compare the scoring system in relation to the burning sensation of mouth and dysphagia using the visual analog scale (VAS) and Dakkak and Bennett grading system for Indian food, respectively, in OSMF patients. This study was a randomized clinical trial incorporating a total of 50 cases of OSMF divided into a control group (antioxidant therapy) and pentoxifylline test cases. Values for burning sensation of the mouth using the VAS and modified Dakkak and Bennett grading system for Indian food were recorded. Statistical analyses were done using t test, Mann -Whitney U test, and one-way analysis of variance (ANOVA) test. Patients subjected to pentoxifylline when compared to the control group showed significant reduction in dysphagia for Indian food. Burning sensation was recorded according to the visual analogue scale. Significant reduction in burning sensation was seen in the pentoxifylline group when compared to the control group. This grading system provides quantitative and qualitative parameters in patients with OSMF.

Dysplastic features relevant to malignant transformation in atrophic epithelium of oral submucous fibrosis: A preliminary study

BACKGROUND

The grading of oral epithelial dysplasia (OED) is not applicable to oral submucous fibrosis (OSMF) cases due to the presence of atrophic epithelium. The mucosal margins associated with resected OSCC specimens are often closely related to transformed cells. In this study, we compared the histomorphological alterations (dysplastic features) in the atrophic epithelium of OSMF patients with the mucosal margins of OSCC associated with OSMF (OSCC-OSMF).

METHODS

We evaluated 17 dysplastic features in 37 patients with OSMF (biopsy site: buccal mucosa) and 37 patients with OSCC-OSMF (mucosal margins involving buccal mucosa) using histopathological staining.

RESULTS

Dysplastic features, such as keratin pearls within rete ridges, nuclear pleomorphism, and atypical mitotic figures, were not observed in the epithelium of the OSMF or OSCC-OSMF groups. Basal cell hyperplasia (P = .016), abnormal superficial mitosis (P = .010), increased nuclear-cytoplasmic ratio (P = .034), and hyperchromasia (P = .031) were predominantly seen in the OSCC-OSMF group. We found no statistically significant differences in the following parameters: irregular epithelial stratification (P = 1.00), loss of basal cell polarity (P = .237), presence of drop-shaped rete ridges (P = .077), increased number of mitotic figures (P = .154), premature keratinization in single cells (P = .499), anisonucleosis (P = .289), anisocytosis (P = .079), cellular pleomorphism (P = .317), and increased number and size of nucleoli (P = .129).

CONCLUSION

Increased basal cell layer hyperplasia, abnormal superficial mitosis, increased nuclear-cytoplasmic ratio, and hyperchromasia are high-risk features for OSMF, and affected patients should be followed on a priority basis for the early detection of OSCC.

Thioctic acid in oral submucous fibrosis (India's disease) - A better tomorrow

Oral submucous fibrosis (OSMF), because of its common occurrence in Indian population is known as India's disease. Regardless of diagnostic and therapeutic developments, oral potentially malignant disorders (PMD) and cancers are disseminating at a distressing rate. There is this prerequisite for unrelenting determination to find out apt treatment options so that malignant transformation may be prevented and more so the prevailing morbidity and mortality. Considering the frequency with which oral submucous fibrosis undergoes malignant transformation with free radicals playing a major part, the role of antioxidants in general and thioctic acid also known as alpha lipoic acid (ALA) in particular need to be studied in these individuals. Previous few studies indicated the use of alpha lipoic acid in oral submucous fibrosis patients leading to improvement in signs and symptoms. So, it led us to set forth and propose probable role of thioctic acid in improving symptoms in these patients. As oral submucous fibrosis poses as a threat with its various signs and symptoms and as a potentially malignant disorder as well as considering the role of free radicals in malignant transformation, we proposed the possible mechanisms behind the commonest signs and symptoms in oral submucous fibrosis and role of alpha lipoic acid in managing these signs and symptoms.

A randomized control trial measuring the effectiveness of a mouth-exercising device for mucosal burning in oral submucous fibrosis

OBJECTIVES

To evaluate effect of ice-cream stick exercise regimen with or without a mouth-exercising device (MED) on mucosal burning sensation in oral submucous fibrosis.

STUDY DESIGN

In total, 282 patients with oral submucous fibrosis were treated with topical corticosteroid and oral antioxidant and the ice-cream stick exercise regimen. Patients in subgroups A1, A2, and A3 were additionally given a new MED. Patients in subgroups A1 and B1 patients with interincisal distance (IID) of 20 to 35 mm were managed without any additional therapy; patients in subgroups A2 and B2 with IID of 20 to 35 mm were additionally managed with intralesional injections; and those in subgroups A3 and B3 with IID less than 20 mm were managed surgically. Subjective evaluation of decrease in the oral mucosal burning was measured on a visual analogue scale (VAS). Analysis of variance and Tukey's multiple post hoc analysis were carried out to present the results.

RESULTS

Patients using the MED, that is, subgroups A1, A2, and A3, showed reduction in burning sensation in the range of 64.8% to 71.1% and 27.8% to 30.9%, whereas in subgroups B1, B2, and B3, reduction in burning sensation ranged from 64.7% to 69.9% and from 29.3% to 38.6% after 6 months. The wo-way analysis of variance indicated statistically significant results in changes in initial VAS scores to 6-monthly VAS scores between MED users and non-MED users.

CONCLUSIONS

The MED helps to enhance the rate of reduction of mucosal burning sensation, in addition to the conventional ice-cream stick regimen, as an adjunct to local and surgical treatment.