|HEAD AND NECK SYMPOSIUM - REVIEW ARTICLE
|Year : 2014 | Volume
| Issue : 3 | Page : 222-226
Oral submucous fibrosis in India: Are we progressing??
PB Hebbar1, R Sheshaprasad2, S Gurudath3, A Pai2, D Sujatha2
1 Department of Oral Medicine and Radiology, Yashas Dental Health Care Centre, Karnataka, India
2 Department of Oral Medicine and Radiology, The Oxford Dental College and Hospital, Karnataka, India
3 Department of Oral Medicine and Radiology, KLE Institute of Dental Sciences, Karnataka, India
|Date of Web Publication||10-Dec-2014|
P B Hebbar
Department of Oral Medicine and Radiology, Yashas Dental Health Care Centre, Karnataka
Source of Support: None, Conflict of Interest: None
Oral submucous fibrosis (OSMF) a condition first described in the 1950s in the modern literature still remains elusive of a cure. For many years this condition had been confined to countries like India, Pakistan, Bangladesh, etc., but now this condition is being reported from Western countries as well. Inspite of intensive research over the years into the etiologic factors of OSMF, a single etiologic factor cannot be pointed out with certainty rather several causative factors have been proposed. Patients suffering with OSMF initially present with a blanched or marble-like pale mucosa, vesiculations, and also intolerance to hot and spicy food. Gradually, the patient may develop fibrous bands in the buccal and labial mucosa which causes a restriction in opening the mouth. The evidence for the various treatment modalities for OSMF is weak hence better documentation of the studies performed with standardized criteria is required. The current review aims to refresh our knowledge regarding OSMF from an Indian perspective and make a few suggestions to fill the lacunae in this field.
Keywords: Aloe vera, lycopene, oral submucous fibrosis, oxitard
|How to cite this article:|
Hebbar P B, Sheshaprasad R, Gurudath S, Pai A, Sujatha D. Oral submucous fibrosis in India: Are we progressing??. Indian J Cancer 2014;51:222-6
| » Introduction|| |
The enigma surrounding oral submucous fibrosis (OSMF) is an undying one. The first mention of a condition resembling OSMF was made by Sushrutha (2500-3000 BC) an ancient Indian doctor as Vidari.  Since the time it was first described in the modern literature in 1952 by Schwartz  there have been numerous articles regarding the various aspects of OSMF till date. Although 60 years have passed by, still there is no obvious cure that has been proven beyond doubt. Instead day by day the number of people getting addicted to such harmful areca nut products with and without tobacco is on the rise, especially the younger age groups. This poses a great threat on a long-term basis as a large segment of the society can be afflicted by disorders like OSMF or even oral cancer. ,,, The magnitude of the situation can be gauged by facts stated in a 2004 review  that India ranks the highest among all the registries in the world for incidence of oral cancer with 75,000-80,000 cases reported each year. For many years this condition had been confined to countries like India, Pakistan, Bangladesh, etc., but now due to higher rates of immigration this condition is being reported from Western countries as well. , In fact an author states that wherever Indians have settled in the world the habit of betel quid chewing is prevalent. 
This epidemic in part is due to the sudden spurt in the number of industries involved in the convenient and inexpensive packaging and vigorous advertising of products like gutka and pan masala which was commercially started in 1980 in India. ,,, Major steps in curbing this serious health issue by the Government are missing mainly due to the fear of affecting the livelihood of farmers and others involved in this industry. Karnataka, a state of India grows about 65% of the total areca nut produced in the country, yet a ban was just recently imposed on gutka after several other states banned the product under the Food safety and standards act. Farmers need to be educated regarding the ill effects and encouraged to grow other crops which can bring them profits.  Recently another Indian state, Maharashtra has decided to ban the manufacture, storage, distribution, and sale of gutka and pan masala. A ban on gutka already exists in other Indian states like Kerala, Madhya Pradesh, Bihar, and Uttar Pradesh but Maharashtra will be the first state to ban both gutka and pan masala. ,, It is estimated that roughly one million people die due to tobacco-related diseases in India annually with a little difference to the gutka industry which is flourishing with approximately 375 brands and a turnover of about 25 billion USD. ,, Stringent measures are needed to bring this epidemic of OSMF under control. The current review aims to refresh our knowledge regarding OSMF from an Indian perspective and make a few suggestions to fill the lacunae in this field.
A few reasons proposed for the increased incidence of OSMF in India:
- The low cost, easy availability, attractive packaging, and aggressive marketing have led to a substantial increase in the number of people initiating this habit and getting addicted to it
- Advertisements portray consumption of these products as confidence boosters or a status symbol giving it a midas touch
- Advertisements also portray these products as breath fresheners thereby attracting a larger audience
- A lack of proper demarcation between the various products such as gutka, pan masala, and their contents
- As smoking is considered a taboo in certain areas of the country, majority of the women take in to tobacco/betel quid chewing
- In India areca nut is deeply rooted in the cultural/religious beliefs of the people, it is considered sacred so is distributed to people during occasions like marriages, etc., and hence people chewing it is not uncommon nor is it objectionable
- There could be a lower reporting of the incidence of OSMF due to minimal symptoms in the early stages and a lack of awareness regarding the same
- Multiple pregnancies combined with poor nutritional status can act as a promoting factor in the presence of habits.
| » Etiopathogenesis|| |
In spite of intensive research over the years into the etiologic factors of OSMF, a single etiologic factor cannot be pointed out with certainty, rather several causative factors have been proposed.
According to a review in 1989,  the etiologic factors can be conveniently divided into initiators and promoters of OSMF. The initiators include - chilies, areca nut, tobacco, and streptococcal infection, whereas the promoters include - anemia (iron deficiency), vitamin deficiencies (B complex and folate), malnutrition (protein), and immunologic derangements. In 1995 Murti et al. emphasized the role of areca nut as the etiologic agent for OSMF.
A review  in 2005 proposes that OSMF could be included under collagen metabolic disorders due to the imbalance in collagen production and breakdown. Elaborate pathways have been described on how there is an increase in collagen production as well as a pathway to explain decreased degradation of collagen thereby leading to an increased concentration of collagen in the tissues. , Most of the current studies are concentrating on the role of areca nut and its constituents in the derangement of the extracellular matrix and collagen imbalance.
Tilakaratne et al.  in 2006 proposed various pathogenetic mechanisms like areca alkaloids causing fibroblast proliferation and increased collagen synthesis, stabilization of collagen structure by tannins and catechins, copper content in arecanut and its contribution in fibrosis, upregulation of cyclo-oxygenase-2, role of fibrogenic cytokines, genetic polymorphisms predisposing to OSF, inhibition of collagen phagocytosis, stabilization of extracellular matrix, and role of collagen-related genes. Angadi et al.  in 2011 restated that areca nut by far is the most probable etiologic agent for OSMF.
| » Clinical Features|| |
Patients suffering with OSMF initially present with a blanched or marble-like pale mucosa, vesiculations, and also intolerance to hot and spicy food. Gradually, the patient may develop fibrous bands in the buccal and labial mucosa which causes a restriction in opening the mouth. ,,, An author has recently suggested an alternative terminology for OSMF due to its clinical features as gutka or areca nut chewers syndrome.  The various components of this syndrome have been enumerated as gutka facies - sunken and stiff cheeks, pseudo proptosis, multiple perioral skin folds; gutka mouth - whitening of the oral mucosa, still oral aperture, poor oral hygiene, bald tongue, chronic non-healing ulcers, retracted soft palate and uvula, unhealthy gingival melanosis, and reduced salivary output. Other components include gutka speech which is peculiar due to lack of mobility of tongue and cheeks, gutka swallowing - suck and swallow, dysphagia and avoidance of eating in public, and lastly some patients present with hearing changes in advanced stages hence gutka hearing.  Interestingly, it has been noted that fibrous bands run only vertically in OSMF. A study reported from Karnataka (India) tries to explain this fact as follows:  The histopathology of normal mucosa reveals that the collagen fibrils are thin and haphazardly arranged whereas in OSMF the collagen bundles are 20-30 μm thick and parallel to the epithelium. It has been proposed that the constant irritation of the mucosa may lead to the change in orientation of collagen fibers and that they align themselves in the direction of stress such as the vertical direction due to opening and closing of the mouth.
| » Classification|| |
Numerous classification systems have been proposed so far, the latest ones being that by Kerr et al. (2011) and by Chandramani et al. (2012).
Kerr et al. 2011, the proposed grading system for OSMF 
- Grade 1 - Mild: Any features of the disease triad for OSF (burning, depapillation, blanching, or leathery mucosa) may be reported - and inter-incisal opening > 35 mm
- Grade 2 - Moderate: Above features of OSF + inter-incisal limitation of opening 20-35 mm
- Grade 3 - Severe: Above features of OSF + inter-incisal opening < 20 mm
- Grade 4A - OSF + other potentially malignant disorder on clinical examination
- Grade 4B - OSF with any grade of oral epithelial dysplasia on biopsy
- Grade 5 - OSF + oral squamous cell carcinoma.
The classification proposed by Chandramani et al. in 2012  closely suits the Indian population and could be utilized in the future studies to standardize reporting.
- Stage 1 (S1) - Stomatitis and/or blanching of oral mucosa
- Stage 2 (S2) - Presence of palpable fibrous bands in buccal mucosa and/or oropharynx, with/without stomatitis
- Stage 3 (S3) - Presence of palpable fibrous bands in buccal mucosa and/or oropharynx, and in any other parts of oral cavity, with/without stomatitis
- Stage 4 (S4) (a) - Any one of the above stage along with other potentially malignant disorders e.g., oral leukoplakia, oral erythroplakia, etc.
- Stage 4 (S4) (b) - Any one of the above stage along with oral carcinoma.
M1. Inter-incisal mouth opening up to or > 35 mm
M2. Inter-incisal mouth opening between 25 mm and 35 mm
M3. Inter-incisal mouth opening between 15 mm and 25 mm
M4. Inter-incisal mouth opening < 15 mm.
A proposed modification for the latest classification is inclusion of dysplasia as suggested by Kerr et al. to better categorize and manage patients. 
| » Treatment|| |
The evidence for the various treatment modalities for OSMF is weak hence better documentation of the studies performed with standardized criteria is required.  Currently, in India studies using natural products such as curcumin, aloe vera, stem cells, and oxitard are ongoing and the results of these are eagerly awaited. A summary of all the old and new treatment modalities is presented in [Table 1]:
1. Suggestions to help curb the OSMF epidemic in India
- Registering trials of OSMF in central agencies and making the results public and available to the Government authorities
- Increasing public awareness through mass media such as television, radio and depicting the hazards of these harmful products
- In rural areas increasing awareness through street plays and door-to-door campaigns
- Appeal for large-scale oral screening for early detection of lesions
- Appeal to Government authorities for ban on manufacture and sale of guthka and pan masala
- Establishing a centralized record/registry to keep track of the changing trends in the incidence of OSMF
- Dental colleges in each state should be advised to adopt a few neighboring villages to screen and treat oral lesions
- Mandatory rural postings for dental college students to reach out to the large neglected rural segment
- Counseling and educating farmers regarding the devastating effects of and tobacco and encouragement to grow other crops to maintain similar revenue
- In private practice every dental practitioner should consider it as his or her responsibility to counsel a patient addicted to areca nut or tobacco products or consider referring them to more qualified specialists or dental hospitals for further assistance. Each practitioner should spend at least 5-10 min with such patients for counseling them.
2. Future research recommendations in India include
- Studies clearly stating and comparing combination of habits such as only areca nut use or betel quid use or guthka or pan masala or the several other forms of smokeless tobacco
- Critical laboratory analysis of the components of the marketed tobacco products to understand any other toxic substances added that could be deleterious
- Comparison studies between different states within India for any differences observed in the incidence, severity, and malignant potential of OSMF
- Large-scale studies including several parameters like age, gender, educational level, occupation details, dietary factors, cultural/religious factors, etc
- Well-designed randomized controlled trials comparing the different treatment modalities such as behavioral, medicinal, physiotherapy, and surgical with large enough sample size to provide meaningful results
- Follow-up studies observing the effects of behavioral counseling techniques in OSMF patients
- Non-areca-related cases of OSMF, need to be better reported and studies should be conducted to investigate the precise etiology in such cases
- Meta-analysis and systematic reviews regarding the etiology and management modalities of OSMF
- Search of alternative medicines in the field of naturopathy and Ayurveda, etc., to achieve reduction in side effects and have long-lasting results.
| » Conclusion|| |
India offers a diverse avenue for research especially in the subject of OSMF as a number of areca nut and tobacco products are available in the market and a large segment of the population is addicted to these products. The need of the hour is to invest wisely in research so as to precisely identify the various contributing factors affecting the disease progression and outcome, provide high quality evidence-based treatment modalities to patients and reduce their suffering, and significantly improving their quality of life.
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