Oral sub-mucous fibrosis (OSMF) disease was discovered in the year 1952 by Schwartz when he treated five Indian women in Kenya. It has been estimated that about 2.5 million people are affected because of oral sub-mucous fibrosis. Most of these persons are in Indian sub-continent – in particular in southern India. OSMF affects not only all age groups but also all socioeconomic strata in India. Introduction of Gutka in the market has increased the incidence of OSMF. Oral sub-mucous fibrosis in the United States exists only in the South Asian population who has the habit of chewing betel nuts.

This article details with the symptoms, causes and treatment of oral sub-mucous fibrosis.

The term oral submucousfibrosis has been derived from the following:

• Oral – indicates mouth
• Sub-mucosal - indicates below the mucosa of the mouth
• Fibrosis – indicates hardening and scarring

Oral sub-mucous fibrosis is a chronic disease of the oral cavity that could weaken a person to a great extent; the main characteristics of this disease are – inflammation and progressive fibrosis of the sub-mucosal tissues. The patient affected by this disease feels burning sensations in his mouth that too while taking hot and spicy foods. Further there will be multiple ulcerations or inflammatory reactions in the oral mucosa. This can cause excessive or decreased salivations and defective gustatory sensations.

This disease causes rigidity of oral mucosa that makes it extremely difficult to open the mouth. The mucosa that is related to the cheeks or the mouth cavity is the site affected mostly; however it is possible that other oral cavity sites including pharynx also could be affected.

The condition is likely to cause malignancy and is mainly associated with betel quid chewing. People in Southeast Asia and India have been practicing this for thousands of years and this is similar to tobacco chewing in western nations. The betel quid mixture contains – areca nut, betel leaf, tobacco, slaked lime and catechu.

During the initial period if you touch the mucosa you will feel that it is wet and leathery; in the advanced stages the resilience of the oral mucosa is lost and it becomes very stiff. Normally this disease starts from the posterior part of the oral cavity and it slowly spreads to the anterior locations.

Symptoms

• Progressive inability to open the mouth due to oral fibrosis and scarring.
• Oral pain and a burning sensation upon consumption of spicy foodstuffs.
• Increased salivation.
• Change of gustatory sensation.
• Pain in the ear or loss of hearing.
• Nasal intonation of voice.
• Mouth becomes dry.
• Thinning and stiffening of the lips.
• Bud-like shrunken uvula.
• Pigmentation of the oral mucosa.
• Impaired mouth movements - eating, whistling, blowing, sucking etc.
• Dysphagia to solids that inability to take solid diet if esophagus is involved.

Signs

• Vesicle on palate with white streaks and superficial ulcerations.
• stiff/small tongue.
• shrunken uvula.
• blanched and atrophic tonsils and Rubbery soft palate with decreased mobility looking like white arch.
• Depigmented and fibrotic gingival, and Sinking cheeks which does not commensurate with age or nutritional status

These signs are followed by leukoplakia which is a pre cancer state and found in 25% of cases of oral sub-mucus fibrosis, severe trismus (interincisal distance less than 15mm) and finally frank cancer due to malignant change throughout the mucosa.

Laboratory findings

• Decreased levels in hemoglobin, iron and protein
• Increased ESR (erythrocyte sedimentation rate)

The reasons for oral submucousfibrosis are as follows:

• Chewable items such as betel nuts contain substances that irritate the oral mucosa thereby making it lose its elasticity. Pan Masala and gutkha contain very high concentration of areca nut and consuming them regularly causes OSWF.
• Consumption of red chilies in large quantities.
• Immunological diseases.
• Climatic conditions that are extreme in nature
• Lack of iron & vitamins in the diet.

The type of treatment to be rendered is dependent mainly on the stage of the disease. If you stop taking Pan Masala at the right time it is possible to reverse the disease. However the existence of this disease is discovered when it reaches the moderate to severe stage in most of the cases.

Two types of treatments are given for Oral sub-mucous fibrosis – medical and surgical. Before treating for this disease it is necessary to get biopsy screening done.

As a part of the treatment the patient should adhere to the following:

• Stop the habit of chewing betel nut and tobacco
• Minimize the consumption of spicy foods and chilies
• Maintain a good oral hygiene.
• Get the third molars extracted.
• Round off the sharp edges of teeth.
• Take Vitamin B Complex, Vitamin A and Vitamin C
• Take iron supplements.
• Practice muscle stretching exercise for the mouth

The following medical treatments are given:

• Weekly sub mucosal intra-lesional injection or topical application of steroids – dexamethasone, Triamcinolone, acetonide, and betamethasone valerate.
• Injection or topical hyaluronidase with or without steroids.
• Intralesional interferon gamma.
• Sub mucosal injection of healthy human placental extracts.

The following surgical treatments are given:

Surgical treatment includes reconstructive surgery by orofacio-maxillary or plastic surgeon. Simple excision of fibrous band is to be avoided to prevent contracture of tissue and exacerbation.