Oral submucous fibrosis: An overview of a challenging entity

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.

Differences among oral carcinomas arising de novo from those associated with oral potentially malignant disorders: a systematic review and meta-analysis

OBJECTIVE

To analyze the frequency of sequential oral squamous cell carcinomas (s-OSCC), preceded by oral potentially malignant disorders, and OSCC de novo (OSCC-dn) and explore differences in their clinicopathologic presentations.

STUDY DESIGN

A structured electronic search strategy identified studies that analyzed frequency, clinical, biological, demographic, biomarkers, and prognostic features of s-OSCC and OSCC-dn according to PRISMA guidelines in PubMed, Scopus, Cochrane Library, and Google Scholar, up to January 31, 2023. Inclusion criteria were original English, Spanish, Portuguese, French, Italian, and German cross-sectional, cohort, and case-control studies. The quality of studies was assessed using the Agency for Research and Health Quality tool and the Newcastle-Ottawa Scale tool.

RESULTS

The final selection included 40 studies. OSCC-dn and s-OSCC represent, respectively, 71% and 29% of cases of OSCC (P = .00), showing a higher percentage of T1 or of T1+T2 in s-OSCC (P < .0001). The association meta-analysis showed OSCC-dn with a significant association. The meta-analysis showed that s-OSCC was significantly associated with smaller tumor size, absence of distant metastases, relapses, male sex, and tumor sites different from tongue; and OSCC-dn was associated with more advanced tumor size, more regional and distant metastases, more advanced stages, and worse survival.

CONCLUSIONS

S-OSCC was less frequent than expected. OSCC-dn seems to have specific clinical, biological, and prognostic features. Future perspectives on oral cancer prevention should address novel approaches and alternatives to screening, such as urgent referral of OSCC-dn.

Role of Antioxidant Vitamins in Oral Submucous Fibrosis: A Narrative Review

Oral submucous fibrosis (OSMF) has a high rate of malignant transformation and is an insidious chronic inflammatory disease. Though this disorder seems to be multifactorial in origin, betel quid chewing appears to be the main etiologic factor. Various treatment strategies have been attempted but none proven to cure the disorder because of its multimodal pathogenesis. Reactive oxygen species (ROS) appear to have a role in cancer formation. As OSMF is an oral premalignant disorder and found to be associated with carcinogens like areca nut and tobacco, it is believed to have some relationship with ROS. Tissue damage due to ROS along with other mechanisms may result in the complex pathophysiology of OSMF. The antioxidant system in the body helps to prevent damage caused by highly reactive ROS and helps in the repair of tissues. To study the levels of oxidative stress and antioxidant vitamins in OSMF condition, the present review was done. We carried out a thorough literature search to identify original reports and studies determining the status of oxidative stress and antioxidant vitamins in OSMF condition using several databases including Google Scholar, PubMed, and Scopus. Our review observed that the oxidative stress increased in the condition of OSMF as shown by an increase in malonaldehyde (MDA) and a decrease in antioxidant vitamins like vitamin A, vitamin C, and vitamin E. Also, after the intake of antioxidant vitamins, there was symptomatic improvement in OSMF patients. With the help of identifying oxidative stress and antioxidant status, we can assess the clinical stage of OSMF and can develop a comprehensive treatment plan.

Serum and salivary Cu/Zn ratio as a diagnostic biomarker for oral submucosal fibrosis: an analysis of trace metals and LOX gene variants

This study aimed to analyze the serum and salivary levels of copper (Cu), zinc (Zn), iron (Fe), chromium (Cr), manganese (Mn) and the Cu/Zn ratio and investigate the association between LOX gene variants (rs18800449 and rs2288393) and oral submucosal fibrosis (OSMF). A total of 250 subjects were included in the study: OSMF patients (n = 50), areca nut chewers without OSMF (n = 100) and controls (n = 100). Trace metals were measured using an atomic absorption spectrophotometer, while LOX gene variants were genotyped using the tetra primer amplification refractory mutation system (tetra ARMS) polymerase chain reaction (PCR) method. The results showed significant variations in serum and salivary Cu, Zn, Fe and Cr levels and serum Mn concentrations among the three groups (p < 0.0001). Serum Cu levels were significantly higher in OSMF patients, while serum Zn levels were significantly lower. Both serum and salivary Cu/Zn ratios demonstrated a statistically significant difference (p < 0.0001) and diagnostic potential to differentiate OSMF from chewers and controls. However, LOX gene variants did not show an association between OSMF and chewers, except for rs1800449 genotypes, which showed a significant and increased risk with the AA genotype in OSMF patients compared to controls (OR = 7.58; 95%CI 2.30-24.97). The study suggests that trace elements and genetic variants may impact the etiology of OSMF. The findings may aid in early diagnosis, suitable treatment, and as a prognostic indicator for disease progression.

PDE12 disrupts mitochondrial oxidative phosphorylation and mediates mitochondrial dysfunction to induce oral mucosal epithelial barrier damage in oral submucous fibrosis

Oral submucous fibrosis (OSF) is a chronic oral mucosal disease. The pathological changes of OSF include epithelial damage and subepithelial matrix fibrosis. This study aimed to reveal the epithelial injury mechanism of OSF. A histopathological method was used to analyze oral mucosal tissue from OSF patients and OSF rats. The expression of PDE12 in the oral epithelium was analyzed by immunohistochemistry. The epithelial-mesenchymal transition (EMT) and tight junction proteins in arecoline-treated HOKs were explored by western blotting. Epithelial leakage was assessed by transepithelial electrical resistance and lucifer yellow permeability. The expression of PDE12 and the mitochondrial morphology, mitochondrial permeability transition pore opening, mitochondrial membrane potential, and mitochondrial reactive oxygen species (mtROS) were evaluated in arecoline-induced HOKs. Oxidative phosphorylation (OXPHOS) complexes and ATP content were also explored in HOKs. The results showed significant overexpression of PDE12 in oral mucosal tissue from OSF patients and rats. PDE12 was also overexpressed and aggregated in mitochondria in arecoline-induced HOKs, resulting in dysfunction of OXPHOS and impaired mitochondrial function. An EMT, disruption of tight junctions with epithelial leakage, and extracellular matrix remodeling were also observed. PDE12 overexpression induced by PDE12 plasmid transfection enhanced the mtROS level and interfered with occludin protein localization in HOKs. Interestingly, knockdown of PDE12 clearly ameliorated arecoline-induced mitochondrial dysfunction and epithelial barrier dysfunction in HOKs. Therefore, we concluded that overexpression of PDE12 impaired mitochondrial OXPHOS and mitochondrial function and subsequently impaired epithelial barrier function, ultimately leading to OSF. We suggest that PDE12 may be a new potential target against OSF.

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.

Efficacy and Safety of Astaxanthin in the Management of Oral Submucous Fibrosis: A Preliminary Randomized Controlled Trial

BACKGROUND

Oral submucous fibrosis (OSMF) is a chronic, potentially malignant disorder characterized by progressive fibrosis of the oral mucosa, leading to restricted mouth opening and discomfort. This study investigates the efficacy and safety of astaxanthin, a potent antioxidant and anti-inflammatory carotenoid, in the comprehensive management of OSMF.

METHODS

A randomized, double-blind, placebo-controlled trial was conducted with 68 eligible participants diagnosed with OSMF. Participants were randomly assigned to the experimental group (astaxanthin capsules, 5 mg twice daily) or the control group (placebo capsules) for 12 weeks. Primary outcomes included changes in mouth opening and burning sensation assessed by Visual Analog Scale (VAS). Adverse events were monitored to evaluate safety.

RESULTS

The experimental group demonstrated a statistically significant improvement in mouth opening compared to the control group over the 12-week intervention (p < 0.001). Additionally, the experimental group reported a significant reduction in burning sensation, as indicated by VAS scores (p < 0.001). Adverse events were generally mild and comparable between groups.

CONCLUSION

This study suggests that astaxanthin may have a positive impact on mouth opening and burning sensation in individuals with OSMF. The safety profile observed supports the feasibility of astaxanthin as a potential therapeutic adjunct in OSMF management. Further research with larger sample sizes and extended follow-up periods is warranted to validate these findings.

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.

Physiotherapeutic Approach in Oral Submucous Fibrosis: A Systematic Review

One of the most poorly recognized and inadequately managed diseases, oral submucous fibrosis progresses over time. Betel nut eating is the foremost cause of oral submucous fibrosis. One such condition is oral submucous fibrosis, which is characterized by severe trismus, disability, and a higher risk of cancer. The mouth opening gradually decreases, which is related to difficulty eating, altered gustatory sensation, and mouth dryness, leading to decreased oral intake. The main and beginning signs include decreased mouth opening, pain, difficulty eating, dry mouth, and blanching of the buccal mucosa. This is treated first with medication, then with exercises for the mouth that a physiotherapist has recommended. However, the function of a physical therapist is not clearly defined. Physiotherapy may be used with other therapies to treat oral submucous fibrosis. Mouth-opening exercises, ultrasound, and other therapeutic interventions are available. This article tries to describe the kind of physical therapy that can be recommended for treating oral submucous fibrosis. It is crucial to understand pain management, physiotherapy management for grade III and IV oral submucous fibrosis various additional exercises, modalities and their ideal dose, and strategy for the long-term effect of the treatments to conduct further research.

Oral squamous cell carcinomas and oral potentially malignant disorders: A Latin American study

OBJECTIVE

To determine the frequency of oral squamous cell carcinoma (OSCC) associated or not with oral potentially malignant disorders (OPMD), and the epidemiological profile and traditional risk factors in Latin America.

METHODS

A retrospective observational study was conducted in 17 Latin American centres. There were included cases of OSCC, analysing age, gender, OSCC and their association with previous OPMD. Clinicopathological variables were retrieved. The condition of sequential-OSCC versus OSCC-de novo (OSCC-dn) was analysed concerning the aforementioned variables. Quantitative variables were analysed using Student's t-test, and qualitative variables with chi-square.

RESULTS

In total, 2705 OSCC were included with a mean age of 62.8 years old. 55.8% were men. 53.75% of the patients were smokers and 38% were common drinkers. The lateral tongue border was the most affected site (24.65%). There were regional variations in OPMD, being leukoplakia the most frequent. Of the overall 2705 OSCC cases, 81.4% corresponded to OSCC-dn, while s-OSCC were 18.6%. Regarding lip vermillion SCC, 35.7% corresponded to de novo lip SCC and 64.3% were associated with previous OPMD.

CONCLUSIONS

In Latin America, OSCC-dn seems to be more frequent with regional variations of some clinical and histopathological features. Further prospective studies are needed to analyse this phenomenon.

Jiawei Danxuan Koukang Alleviates Arecoline Induced Oral Mucosal Lesions: Network Pharmacology and the Combined Ultra-High Performance Liquid Chromatography (UPLC) and Mass Spectrometry (MS)

Purpose

Arecoline is one of the main toxic components of arecoline to cause oral mucosal lesions or canceration, which seriously affects the survival and life quality of patients. This study analyzed the mechanism of Jiawei Danxuan Koukang (JDK) in alleviating arecoline induced oral mucosal lesions, to provide new insights for the treatment of oral submucosal fibrosis (OSF) or cancerosis.

Methods

Metabolomics was applied to analyze the composition of JDK and serum metabolites. The active ingredients of JDK were analyzed by the combined ultra-high performance liquid chromatography and mass spectrometry. The target network of JDK, metabolites and OSF was analyzed by network pharmacology, and molecular docking. Oral mucosal lesions and fibrosis were analyzed by HE and Masson staining. Cell differentiation, proliferation and apoptosis were detected. The expressions of α-SMA, Collagen I, Vimentin, Snail, E-cadherin, AR and NOTCH1 were detected by Western blot.

Results

Arecoline induced the gradual atrophy and thinning of rat oral mucosal, collagen accumulation, the increase expressions of fibrosis-related proteins and Th17/Treg ratio. JDK inhibited arecoline-induced oral mucosal lesions and inflammatory infiltration. Arecoline induced changes of serum metabolites in Aminoacyl-tRNA biosynthesis, Alanine, aspartate and glutamate metabolism and Arginine biosynthesis pathways, which were reversed by M-JDK. Quercetin and AR were the active ingredients and key targets of JDK, metabolites and OSF interaction. Arecoline promoted the expression of AR protein, and the proliferation of oral fibroblasts. Quercetin inhibited the effect of arecoline on oral fibroblasts, but was reversed by AR overexpression. Arecoline induced NOTCH1 expression in CAL27 and SCC-25 cells, and promoted cell proliferation, but was reversed by M-JDK or quercetin.

Conclusion

JDK improved the arecoline-induced OSF and serum metabolite functional pathway. Quercetin targeted AR protein to improve arecoline-induced OSF. JDK and quercetin inhibited arecoline-induced NOTCH1 protein expression in CAL27 and SCC-25 cells to play an anti-oral cancer role.

Oral Submucous Fibrosis and Scleroderma: A Review of the Etiopathogenesis, Clinicopathological Correlation, and Management Aspects

Oral submucous fibrosis (OSMF) is a chronic, progressive, insidious premalignant disease with multifactorial etiology affecting any part of the oral cavity and sometimes the pharynx by triggering a rapid onset of trismus and dysphagia due to stiffness at the lips, cheek, pharynx, and upper oesophageal region. Submucous fibrosis resembles many auto-immune, dermatological, mucocutaneous, and fibrotic lesions that include scleroderma, amyloidosis, iron deficiency anemia, and systemic or generalized fibromatosis clinically and histologically. Several authors established an association between oral submucous fibrosis and scleroderma with predominant oral manifestations on the basis of similarity in clinical and histological characteristics despite different pathogenesis and prognostic aspects. Scleroderma or systemic sclerosis is an autoimmune connective tissue disorder clinically manifested as fibrosis of the skin, blood vessels, and visceral organs with or without the involvement of the oral cavity. Thus, understanding the disease mechanism, appropriate early diagnosis, and clinical management of these two entities play an important role in disease prognosis and treatment outcomes. The present review was carried out to briefly present a concise overview of the etiopathogenesis, clinical, histological, diagnosis, and management aspects of OSMF and scleroderma based on the available literature, with special emphasis on similarities and differences between these two entities subsequently aiding in appropriate treatment planning.

Comparison Between Clinical Outcome of Intralesional Human Placental Extract Alone and Topical Application of Placental Extract Gel After Fibrotomy in Oral Submucous Fibrosis

BACKGROUND

Oral submucous fibrosis (OSMF) is a premalignant condition prevalent in our country. Juxtaepithelial inflammation with progressive hyalinization of the lamina propria results in stiffness and fibrosis of the oral mucosa, characterised by trismus, ankyloglossia, and a burning sensation. Various methods of treatment have been tried in these cases, which include placental extract injections and the cutting of fibrous bands. In this study, we aim to compare the outcome of intra-lesional placental extract injection with fibrotomy and placental extract gel application in OSMF.

METHODOLOGY

This prospective interventional study included 58 patients clinically diagnosed with OSMF grades II and III at a rural tertiary care hospital between January 2021 and August 2022. The patients were randomised into two groups: group I received 1 ml of intra-lesional human placental extract injection in the submucosal plane of the buccal mucosa and retro-molar trigone (RMT) once a week for five consecutive weeks, and group II was subjected to a transverse division of fibrotic bands in the submucosal plane under general anaesthesia. The surgical wound was left open, and swabs soaked in human-purified placental extract gel were placed in the wound for two hours twice daily until the surgical wound was epithelialized and healed. The patients in both groups I and II were advised to do jaw opening exercises, and weekly follow-up was done. Findings with regard to maximum mouth opening, colour of mucosa, and burning sensation in the oral cavity based on a Likert scale were documented. At the end of five months, the pre-treatment and post-treatment results documented were compared.

RESULTS

All patients were between 20 and 60 years of age and were addicted to chewing areca nuts with tobacco. Bilateral involvement was present in all patients, with extension into the RMT and soft palate seen in 31%. Improvement in mouth opening was between 4 mm and 6 mm in group II, and relief of burning sensation and mucosal colour was better in group I.

CONCLUSION

Intra-lesional placental extract injections help in the improvement of the mucosa and relief from the burning sensation. Fibrotomy with placental extract gel application is better at relieving trismus in OSMF. Aggressive mouth-opening exercises may improve mouth opening following the above procedures.

Evaluation of Nicotine Dependence Among Smokeless Tobacco Users Using the Fagerstrom Nicotine Dependence Scale for Smokeless Tobacco

Nicotine dependence is a current indwelling and challenging health burden among smokeless tobacco users as it involves the compulsive use of a substance despite its known harmful effects. The evaluation of nicotine dependence is challenging as it involves physical and psychological dependence due to nicotine in smokeless tobacco.

AIM AND OBJECTIVE

The primary aim is to assess the nicotine dependence in a group of smokeless tobacco by using a six-question Fagerstrom Test for Nicotine Dependence for Smokeless Tobacco (FTND-ST) and to assess the nicotine dependence among three groups, namely Group - 1, who were exclusively pan masala, gutka chewers, Group - 2, who were exclusively Hans users, and Group - 3, who were exclusively betel quid with smokeless tobacco chewers.

MATERIALS AND METHODS

Only those who use smokeless tobacco in the age groups between 21 to 70 years were randomly selected. The total sample size is 100 patients. The age groups were divided into 21-28, 29-35, 36-42, 43-49, 50-56, 57-63, and 64-70. Informed consent was obtained from the participants of the study.

RESULTS

The Hans chewers are predominantly females. Pan masala and gutka chewers are predominantly males.

CONCLUSION

Smokeless tobacco chewers like pan masala were found to have high mean nicotine dependence Fagerstrom score than Hans and betel quid with smokeless tobacco chewers.

Molecular Mechanisms of Malignant Transformation of Oral Submucous Fibrosis by Different Betel Quid Constituents-Does Fibroblast Senescence Play a Role?

Betel quid (BQ) is a package of mixed constituents that is chewed by more than 600 million people worldwide, particularly in Asia. The formulation of BQ depends on a variety of factors but typically includes areca nut, betel leaf, and slaked lime and may or may not contain tobacco. BQ chewing is strongly associated with the development of potentially malignant and malignant diseases of the mouth such as oral submucous fibrosis (OSMF) and oral squamous cell carcinoma (OSCC), respectively. We have shown recently that the constituents of BQ vary geographically and that the capacity to induce disease reflects the distinct chemical composition of the BQ. In this review, we examined the diverse chemical constituents of BQ and their putative role in oral carcinogenesis. Four major areca alkaloids—arecoline, arecaidine, guvacoline and guvacine—together with the polyphenols, were identified as being potentially involved in oral carcinogenesis. Further, we propose that fibroblast senescence, which is induced by certain BQ components, may be a key driver of tumour progression in OSMF and OSCC. Our study emphasizes that the characterization of the detrimental or protective effects of specific BQ ingredients may facilitate the development of targeted BQ formulations to prevent and/or treat potentially malignant oral disorders and oral cancer in BQ users.