Aloe vera in treatment of oral submucous fibrosis: A systematic review and meta-analysis

Interventions for managing oral submucous fibrosis

BACKGROUND

Oral submucous fibrosis (OSF) is a chronic disease of the oral cavity that causes progressive constriction of the cheeks and mouth accompanied by severe pain and reduced mouth opening. OSF has a significant impact on eating and swallowing, affecting quality of life. There is an increased risk of oral malignancy in people with OSF. The main risk factor for OSF is areca nut chewing, and the mainstay of treatment has been behavioural interventions to support habit cessation. This review is an update of a version last published in 2008.

OBJECTIVES

To evaluate the benefits and harms of interventions for the management of oral submucous fibrosis.

SEARCH METHODS

We used standard, extensive Cochrane search methods. The latest search date was 5 September 2022.

SELECTION CRITERIA

We considered randomised controlled trials (RCTs) of adults with a biopsy-confirmed diagnosis of OSF treated with systemic, locally delivered or topical drugs at any dosage, duration or delivery method compared against placebo or each other. We considered surgical procedures compared against other treatments or no active intervention. We also considered other interventions such as physiotherapy, ultrasound or alternative therapies.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Our primary outcomes were 1. participant-reported resumption of normal eating, chewing and speech; 2. change or improvement in maximal mouth opening (interincisal distance); 3. improvement in range of jaw movement; 4. change in severity of oral/mucosal burning pain/sensation; 5.

ADVERSE EFFECTS

Our secondary outcomes were 6. quality of life; 7. postoperative discomfort or pain as a result of the intervention; 8. participant satisfaction; 9. hospital admission; 10. direct costs of medication, hospital bed days and any associated inpatient costs for the surgical interventions. We used GRADE to assess certainty of evidence for each outcome.

MAIN RESULTS

We included 30 RCTs (2176 participants) in this updated review. We assessed one study at low risk of bias, five studies at unclear risk of bias and 24 studies at high risk of bias. We found diverse interventions, which we categorised according to putative mechanism of action. We present below our main findings for the comparison 'any intervention compared with placebo or no active treatment' (though most trials included habit cessation for all participants). Results for head-to-head comparisons of active interventions are presented in full in the main review. Any intervention versus placebo or no active treatment Participant-reported resumption of normal eating, chewing and speech No studies reported this outcome. Interincisal distance Antioxidants may increase mouth opening (indicated by interincisal distance (mm)) when measured at less than three months (mean difference (MD) 3.11 mm, 95% confidence interval (CI) 0.46 to 5.77; 2 studies, 520 participants; low-certainty evidence), and probably increase mouth opening slightly at three to six months (MD 8.83 mm, 95% CI 8.22 to 9.45; 3 studies, 620 participants; moderate-certainty evidence). Antioxidants may make no difference to interincisal distance at six-month follow-up or greater (MD -1.41 mm, 95% CI -5.74 to 2.92; 1 study, 90 participants; low-certainty evidence). Pentoxifylline may increase mouth opening slightly (MD 1.80 mm, 95% CI 1.02 to 2.58; 1 study, 106 participants; low-certainty evidence). However, it should be noted that these results are all less than 10 mm, which could be considered the minimal change that is meaningful to someone with oral submucous fibrosis. The evidence was very uncertain for all other interventions compared to placebo or no active treatment (intralesional dexamethasone injections, pentoxifylline, hydrocortisone plus hyaluronidase, physiotherapy). Burning sensation Antioxidants probably reduce burning sensation visual analogue scale (VAS) scores at less than three months (MD -30.92 mm, 95% CI -31.57 to -30.27; 1 study, 400 participants; moderate-certainty evidence), at three to six months (MD -70.82 mm, 95% CI -94.39 to -47.25; 2 studies, 500 participants; moderate-certainty evidence) and at more than six months (MD -27.60 mm, 95% CI -36.21 to -18.99; 1 study, 90 participants; moderate-certainty evidence). The evidence was very uncertain for the other interventions that were compared to placebo and measured burning sensation (intralesional dexamethasone, vasodilators). Adverse effects Fifteen studies reported adverse effects as an outcome. Six of these studies found no adverse effects. One study evaluating abdominal dermal fat graft reported serious adverse effects resulting in prolonged hospital stay for 3/30 participants. There were mild and transient general adverse effects to systemic drugs, such as dyspepsia, abdominal pain and bloating, gastritis and nausea, in studies evaluating vasodilators and antioxidants in particular.

AUTHORS' CONCLUSIONS

We found moderate-certainty evidence that antioxidants administered systemically probably improve mouth opening slightly at three to six months and improve burning sensation VAS scores up to and beyond six months. We found only low/very low-certainty evidence for all other comparisons and outcomes. There was insufficient evidence to make an informed judgement about potential adverse effects associated with any of these treatments. There was insufficient evidence to support or refute the effectiveness of the other interventions tested. High-quality, adequately powered intervention trials with a low risk of bias that compare biologically plausible treatments for OSF are needed. It is important that relevant participant-reported outcomes are evaluated.

Drug treatment for oral submucous fibrosis: an update

OBJECTIVE

The aim of this review is to evaluate the different medicinal interventions available for the management of oral submucous fibrosis (OSF).

MATERIALS AND METHODS

We conducted a comprehensive electronic search on PubMed, Web of Science, and Cochrane Library databases for articles related to OSF patients treated with medications from December 2011 to September 2022. GRADE system was used to evaluate the evidence quality. The reporting of the systematic review is in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocol. The main outcomes were the improvement of maximum mouth opening, burning sensation, cheek flexibility, and tongue protrusion.

RESULTS

Twenty-nine randomized controlled trials (RCTs), five clinical trials (CCTs) were included, and the use of drugs for OSF treatment were evaluated. Drugs like steroids, hyaluronidase, pentoxifylline, lycopene, curcumin, dpirulina, aloe vera, omega3, oxitard, allicin, colchicine have been used. It was found that drugs with evidence high quality were salvia miltiorrhiza combined with triamcinolone acetonide, lycopene, pentoxifylline, curcumin, and aloe vera, and those with evidence moderate quality were allicin, colchicine, omega 3, and oxitard.

CONCLUSION

Based on the results of our comprehensive analysis, for long-term treatment, we found lycopene with low side effects, whereas for relieving the symptoms of severe burning sensation, aloe vera is the most effective. Although the recent review has made some progress, drug therapy for OSF remains unclear, and more high-quality RCTs are needed to identify better treatments for OSF.

Oral Submucous Fibrosis: A Review of the Current Concepts in Management

Oral submucous fibrosis (OSMF) is a precancerous disorder of the submucosa that causes inflammation and progressive fibrosis, leading to pronounced stiffness and trismus. Chewing betel nuts is a significant risk factor for OSMF in India. Arecoline from betel nuts and copper, which causes fibroblast dysfunction and the development of fibrotic bands, are the main components of betel quid. OSMF is distinguished by fibrosis in the submucosal region, which affects the majority of the oral cavity and results in advanced lockjaw due to rigidity in the lips, pharynx, cheeks, and upper third of the oesophageal canal, which progresses to dysphagia. The prevalence of OSMF is rising, particularly among younger generations, as more commercially available areca nut products like gutka (chewing tobacco) and others are being introduced. The severity of OSMF develops as the practice continues and is permanent. It also persists even after chewing has been stopped. The hallmark of oral submucous fibrosis (OSF) is abnormal collagen deposition. It is a precancerous condition and progresses to malignant tumours. Symptoms include ulcers, xerostomia, submucous fibrosis, burning sensation, and a reduction in mouth opening. Each of these drastically reduces the patient's quality of life. In the past, many treatment modalities have been tried but none of them has resulted in a cure for the disease. The primary focus of the treatment is to reduce the signs and symptoms so that the patient can have a better quality of life. Along with principles, conservative, medical, and surgical management issues have also been covered.

Oral Submucous Fibrosis: Etiological Mechanism, Malignant Transformation, Therapeutic Approaches and Targets

Oral submucosal fibrosis (OSF) is a chronic, progressive and potentially malignant oral disorder with a high regional incidence and malignant rate. With the development of the disease, the normal oral function and social life of patients are seriously affected. This review mainly introduces the various pathogenic factors and mechanisms of OSF, the mechanism of malignant transformation into oral squamous cell carcinoma (OSCC), and the existing treatment methods and new therapeutic targets and drugs. This paper summarizes the key molecules in the pathogenic and malignant mechanism of OSF, the miRNAs and lncRNAs with abnormal changes, and the natural compounds with therapeutic effects, which provides new molecular targets and further research directions for the prevention and treatment of OSF.

Comparative Effectiveness of Medicinal Interventions for Oral Submucous Fibrosis: A Network Meta-Analysis

OBJECTIVES

This network meta-analysis presents an exhaustive description and comparison of the available medical interventions for the management of oral submucous fibrosis (OSMF).

MATERIALS AND METHODS

A systematic review and network meta-analysis was conducted after registration with PROSPERO. (PROSPERO ID CRD42022303441). Databases (PubMed, Cochrane, EMBASE, Web of Science, and others) were searched for randomized clinical trials (RCT) trials from inception till September 2022 for the medical interventions in OSMF. The primary outcome was the improvement in mouth opening. The secondary outcomes were improvement in burning sensation, tongue protrusion, and cheek flexibility. The interventions were ranked according to their efficacy based on the surface under the cumulative ranking.

RESULTS

47 studies including 2393 patients were assessed for quantitative analysis. For mouth opening, the combined treatment with steroid, hyaluronidase, and antioxidant was most effective [MD, 7.05 (95%CI 1.76,12.34)], followed by the combination of oral antioxidants with injectable steroids, [MD, 3.80 (95%CI -0.44,8.03)]. Additionally, the combined treatment with steroid, hyaluronidase, and antioxidant was most effective in reducing the burning sensation [MD, -8.62(-10.95,-6.30)], followed by aloe vera [MD, -8.45(-10.40,-6.49)] and pentoxifylline [MD -7.57(-9.46,-5.68)]. For tongue protrusion, curcumin was most effective followed by antioxidants. Most of the drugs used were reported to cause negligible or mild adverse effects.

CONCLUSION

This network meta-analysis reported the efficacy of medicinal interventions in OSMF patients compared to the placebo in the improvement of mouth opening and burning sensation, and cheek flexibility. The methodological quality of included RCTs was low. Well-designed studies are recommended to obtain strong evidence.

Efficacy of lycopene for management of oral potentially malignant disorders: A systematic review and meta-analysis

OBJECTIVE

The aim of this study was to investigate the available evidence on the efficacy of lycopene in the management of oral potentially malignant disorders (OPMDs).

STUDY DESIGN

PubMed, Scopus, Web of Science, Google Scholar, China National Knowledge Infrastructure, and ProQuest databases were searched up to April 20, 2022. All clinical trials that assessed the efficacy of lycopene (I) on the signs/symptoms (O) of patients with OPMDs (P) in comparison to either active control or placebo (C) were included. Meta-analysis was conducted using the RevMan software (Cochrane Collaboration, London, UK).

RESULTS

A total of 27 clinical trials (20 on oral submucosa fibrosis [OSF], 5 on oral lichen planus [OLP], and 2 on leukoplakia) were included. Overall, lycopene was efficacious in reducing signs and symptoms of OSF, OLP, and leukoplakia. The pooled data revealed comparable efficacy of lycopene and prednisolone in reducing pain and promoting clinical resolution of OLP. Additionally, the pooled data reported comparable efficacy of lycopene and conventional controls in improving the mouth opening and tongue protrusion in patients with OSF.

CONCLUSIONS

The results reveal promising effects of lycopene in alleviating signs and symptoms of OSF, OLP, and leukoplakia. However, owing to the observed heterogeneity and short follow-up periods, further well-designed studies with long-term therapy and follow-up are highly recommended.

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.

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.

Nanoparticulate strategies for the delivery of miRNA mimics and inhibitors in anticancer therapy and its potential utility in oral submucous fibrosis

MicroRNAs (miRNAs) are naturally occurring noncoding RNAs with multiple functionalities. They are dysregulated in several conditions and can serve as disease biomarkers, therapeutic targets and therapeutic agents. Translation of miRNA therapeutics to the clinic poses several challenges related to the safe and effective delivery of these agents to the site of action. Nanoparticulate carriers hold promise in this area by enhancing targeting efficiency and reducing off-target effects. This paper reviews recent advances in the delivery strategies of miRNAs in anticancer therapy, with a focus on lipid-based, polymeric, inorganic platforms, cell membrane-derived vesicles and bacterial minicells. Additionally, this review explores the potentiality of miRNAs in the treatment of oral submucous fibrosis, a potentially premalignant condition of the oral cavity with no definitive treatment to date.

Efficacy of Lycopene in the Treatment of Oral Submucous Fibrosis: A Meta-analysis of Randomized Controlled Trials

OBJECTIVES

The aim of this meta-analysis was to systematically evaluate the efficacy of lycopene in improving maximum mouth opening and other clinical symptoms in patients with oral submucous fibrosis (OSF).

METHODS

We searched 5 databases: PubMed, Web of Science, Embase, The Cochrane Library, and EBSCO. Randomized controlled trials were collected to evaluate the efficacy of lycopene in the treatment of OSF. Each database was searched from inception to April 30, 2019. The RevMan 5.3 software was used for this meta-analysis.

RESULTS

The included studies were 7 randomized controlled trials involving 758 patients with OSF. The results of this meta-analysis showed that lycopene was significantly more effective in improving maximum mouth opening in OSF patients than placebo treatment (mean difference [MD]: 3.15; 95% confidence interval [CI]: 2.19-4.10, P < .0001, I² = 0%). Compared with control groups, lycopene could significantly increase the maximum mouth opening in patients with OSF after 1 month of treatment (MD, 2.40; 95% CI, 2.22-2.58; P = .91; I² = 0%), 2 months of treatment (MD, 3.19; 95% CI, 2.87-3.51; P = .93; I² = 0%), and 3 months of treatment (MD, 4.89; 95% CI, 4.51-5.28; P = .86; I² = 0%). However, no significant difference was found in alleviation of burning sensation after 1 month (risk ratio [RR], 1.04; 95% CI, 0.89-1.23; P = .73; I² = 0%), 2 months (RR, 0.98; 95% CI, 0.73-1.31; P = .69; I² = 0%), and 3 months of treatment (RR, 0.84; 95% CI, 0.47-1.52; P = .81; I² = 0%); tongue protrusion (MD, -1.59; 95% CI, -4.15 to 0.97; P = .12; I² = 58%); and pain associated with the lesion after 1 month (RR, 1.05; 95% CI, 0.92-1.21; P = .77; I² = 0%), 2 months (RR, 0.95; 95% CI, 0.75-1.19; P = .35; I² = 0%), and 3 months (RR, 0.95; 95% CI, 0.68-1.33; P = .14; I² = 51%) in patients with OSF between lycopene and control groups.

CONCLUSIONS

The results of this meta-analysis showed that lycopene is more effective for improving symptoms of maximum mouth opening than placebo groups and control groups, but there were no significant differences in burning sensation, pain associated with lesion, and tongue protrusion in patients with OSF compared with control groups.

Aloe vera and health outcomes: An umbrella review of systematic reviews and meta-analyses

This umbrella review aims to summarize the effects of Aloe vera on health outcomes and assess the strength of evidence. PubMed, Scopus, Embase, Cochrane database of systematic reviews, CINAHL, and AMED were searched from inception to October, 2019 for systematic reviews and meta-analyses of clinical trials that investigated the effects of Aloe vera on health outcomes. Two independent reviewers extracted data, assessed the methodological quality, and rated the credibility of evidence according to established criteria. Ten articles reporting 71 unique outcomes of Aloe vera were included. Of these, 47 (67%) were nominally statistically significant based on random-effects model (p ≤ .05). Only 3 outcomes were supported by highly suggestive evidence, whereas 42 outcomes were supported by weak evidence. The highly suggestive evidence supported benefits of Aloe vera in the prevention of second-degree infusion phlebitis (RR: 0.18, 95% CI: 0.10-0.32, p-value: 1.75 × 10^-9 ) and chemotherapy-induced phlebitis based on overall incidence (OR: 0.13, 95% CI: 0.08-0.20, p-value: 9.68 × 10^-20 ) and incidence of the second degree of severity (OR: 0.10, 95% CI: 0.07-0.14, p-value: 3.41 × 10^-35 ). However, the majority of the evidence were limited by small sample size and poor methodological quality. Therefore, despite the overall favorable effect of Aloe vera, more robust studies are needed.

Efficacy of curcumin for recurrent aphthous stomatitis: a systematic review

BACKGROUND

Recurrent aphthous stomatitis (RAS) is the most common ulcerative lesion of the oral mucosa. The management of RAS is quite challenging with no definitive cure.

OBJECTIVE

The present systematic review aimed to summarize the available evidence regarding the efficacy of curcumin in the management of RAS.

METHODS

PubMed, Scopus and Web of Science databases were searched in June 2020 for all relevant studies. Clinical trials that assessed the efficacy of curcumin for the management of RAS were included. The primary outcomes were pain and/or clinical improvement.

RESULTS

Eight studies involving 439 subjects were included. The efficacy of curcumin was compared with 1% triamcinolone in four studies, glycerin vehicle in one study, placebo in one study, and honey in one study. Overall, the included studies reported a good efficacy of curcumin in reducing pain and ulcers size in patients with RAS. Four studies found curcumin as effective as triamcinolone in relieving signs and symptoms of RAS. Three studies reported superior results with curcumin as compared with control groups.

CONCLUSION

The limited available evidence suggests that curcumin have potential benefits in alleviating pain and accelerating healing in patients with RAS. Further well-designed clinical trials with standardized curcumin formulations are highly recommended.

Efficacy of hyaluronidase combined with corticosteroids in treatment of oral submucous fibrosis: A meta-analysis of randomized controlled clinical trials

OBJECTIVE

This meta-analysis was performed to systematically evaluate the efficacy of hyaluronidase combined with corticosteroids compared with other drugs in improving maximum mouth opening and alleviating the burning sensation in patients with oral submucous fibrosis (OSF).

METHODS

PubMed, Embase, Web of Science and the Cochrane Library were searched. RevMan 5.3 software was used for the meta-analysis.

RESULTS

Six studies involving 244 patients with OSF were analysed. No significant difference in improvement of maximum mouth opening was found between the hyaluronidase and control groups (lycopene, pentoxifylline, aloe vera, dexamethasone, Turmix [curcumin + piperine] and isoxsuprine) at 1 month (mean difference [MD]: 0.32, 95% confidence interval [CI]: -0.92-1.56, P = .61, I²  = 57%), 2 months (MD: 0.49, 95% CI: -0.14-1.12, P = .12, I²  = 41%) or 3 months (MD: 0.40, 95% CI: -1.08-1.87, P = .60, I²  = 92%). Additionally, no statistically significant difference was found in alleviation of the burning sensation between the two groups at 1 month (MD: 0.54, 95% CI: -0.62-1.71, P = .36, I²  = 0%), 2 months (MD: 0.53, 95% CI: -0.85-1.91, P = .45, I²  = 0%) or 3 months (MD: 0.64, 95% CI: -1.07 to 2.35, P = .46, I²  = 0%).

CONCLUSIONS

According to this meta-analysis, weak evidence indicates that hyaluronidase combined with corticosteroids has no additional clinical benefit over control drugs (lycopene, pentoxifylline, aloe vera, dexamethasone, Turmix and isoxsuprine) in improving maximum mouth opening and alleviating the burning sensation in patients with OSF. Therefore, more high-quality, multi-centre randomized controlled trials with larger samples are needed to further assess the efficacy of hyaluronidase combined with corticosteroids in the treatment of OSF.

Clinical efficacy of an Aloe Vera gel versus a 0.12% chlorhexidine gel in preventing traumatic ulcers in patients with fixed orthodontic appliances: a double-blind randomized clinical trial

Traumatic oral ulceration (TOU) is one of the most common side effects of orthodontic treatments. The objective of this trial is to compare the clinical efficacy of an 80% Aloe Vera gel, prepared using a master formula, versus a commercial 0.12% Chlorhexidine (CHX) gel for TOU prevention in participants wearing fixed orthodontic appliances. This report represents a single-centre, university-based, double-blinded, randomized controlled trial with 2 parallel arms. Patients aged 12 years or older, in the permanent dentition, and about to start fixed orthodontic treatment in this university setting were randomly allocated to use either Aloe Vera or CHX gel, following the cementation procedure. Pre-treatment and 1 month after the cementation clinical assessment and digital photographic images were taken of the teeth and assessed by 2 clinical assessors for the presence or absence of TOUs. A total of 140 were randomized and completed the trial. The overall prevalence of TOUs was 43.6%. Overall 5.7% of patients treated with Aloe Vera gel showed did not suffer from TOUs, whereas in the CHX arm, a total of 57 (81.4%) were affected by this outcome reaching a significant result (p < 0.001). In terms of relative risk (RRs) and confidence intervals (CIs), Aloe Vera provided better results than CHX with an RR of 0.07 (95%CI 0.03-0.16; p < 0.001), and with a patients' number needed to treat of 1.3 (95%CI 1.16-1.54). There were no adverse effects. These results suggest that Aloe Vera gel administration in patients with fixed orthodontic appliances could be important for effective prevention of TOU.

Oral Submucous Fibrosis: A Review on Etiopathogenesis, Diagnosis, and Therapy

Oral submucous fibrosis (OSF) is characterized by abnormal collagen deposition. It is a precancerous disorder and transforms into a malignant tumor in 1.5–15% of all cases. Symptoms include submucous fibrosis, ulceration, xerostomia, a burning sensation, and restricted mouth opening. All of these greatly interfere with patient quality of life. The present review introduces OSF from a molecular perspective and summarizes what is known about its underlying mechanisms, diagnostic biomarkers, and therapeutic interventions. In addition to the aggressive treatment of OSF, its prevention is also important. Future research should, therefore, focus on improving the oral health literacy of the patients susceptible to OSF.