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  Table of Contents  
HEAD AND NECK SYMPOSIUM - REVIEW ARTICLE
Year : 2014  |  Volume : 51  |  Issue : 3  |  Page : 222-226
 

Oral submucous fibrosis in India: Are we progressing??


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 Publication10-Dec-2014

Correspondence Address:
P B Hebbar
Department of Oral Medicine and Radiology, Yashas Dental Health Care Centre, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-509X.146724

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 » Abstract 

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

How to cite this URL:
Hebbar P B, Sheshaprasad R, Gurudath S, Pai A, Sujatha D. Oral submucous fibrosis in India: Are we progressing??. Indian J Cancer [serial online] 2014 [cited 2019 Sep 21];51:222-6. Available from: http://www.indianjcancer.com/text.asp?2014/51/3/222/146724



 » Introduction Top


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. [1] Since the time it was first described in the modern literature in 1952 by Schwartz [2] 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. [3],[4],[5],[6] The magnitude of the situation can be gauged by facts stated in a 2004 review [7] 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. [8],[9] In fact an author states that wherever Indians have settled in the world the habit of betel quid chewing is prevalent. [10]

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. [7],[11],[12],[13] 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. [14] 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. [12],[15],[16] 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. [7],[11],[14] 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 Top


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, [17] 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 [18] 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. [1],[18] 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. [13] 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. [1] in 2011 restated that areca nut by far is the most probable etiologic agent for OSMF.


 » Clinical Features Top


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. [2],[19],[20],[21] An author has recently suggested an alternative terminology for OSMF due to its clinical features as gutka or areca nut chewers syndrome. [22] 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. [22] 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: [23] 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 Top


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 [24]

  • 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 [25] closely suits the Indian population and could be utilized in the future studies to standardize reporting.

Clinical staging

  • 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.


Functional staging

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. [26]


 » Treatment Top


The evidence for the various treatment modalities for OSMF is weak hence better documentation of the studies performed with standardized criteria is required. [27] 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]:
Table 1: Various treatment modalities for oral submucous fibrosis

Click here to view


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 Top


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.[48]

 
 » References Top

1.
Angadi PV, Rao SS. Areca nut in pathogenesis of oral submucous fibrosis: Revisited. Oral Maxillofac Surg 2011;15:1-9.  Back to cited text no. 1
    
2.
Jayanthi V, Probert CS, Sher KS, Mayberry JF. Oral submucosal fibrosis: A preventable disease. Gut 1992;33:4-6.  Back to cited text no. 2
    
3.
Gupta PC. Gutka: A major new tobacco hazard in India. Tob Control 1999;8:134.  Back to cited text no. 3
[PUBMED]    
4.
Sharma DC. Betel quid and areca nut are carcinogenic without tobacco. Lancet Oncol 2003;4:587.  Back to cited text no. 4
[PUBMED]    
5.
Gupta PC. Mouth cancer in India: A new epidemic? J Indian Med Assoc 1999;97:370-3.  Back to cited text no. 5
    
6.
Gupta PC, Sinor PN, Bhonsle RB, Pawar VS, Mehta HC. Oral submucous fibrosis in India: A new epidemic? Natl Med J India 1998;11:113-6.  Back to cited text no. 6
    
7.
Nair U, Bartsch H, Nair J. Alert for an epidemic of oral cancer due to use of the betel quid substitutes gutkha and pan masala: A review of agents and causative mechanisms. Mutagenesis 2004;19:251-62.  Back to cited text no. 7
    
8.
Pickwell SM, Schimelpfening S, Palinkas LA. ′Betelmania′. Betel quid chewing by Cambodian women in the United States and its potential health effects. West J Med 1994;160:326-30.  Back to cited text no. 8
    
9.
van der Waal I. Potentially malignant disorders of the oral and oropharyngeal mucosa; terminology, classification and present concepts of management. Oral Oncol 2009;45:317-23.  Back to cited text no. 9
[PUBMED]    
10.
Chiba I. Prevention of betel quid chewers′ oral cancer in the Asian-Pacific area. Asian Pac J Cancer Prev 2001;2:263-9.  Back to cited text no. 10
[PUBMED]    
11.
Hazarey VK, Erlewad DM, Mundhe KA, Ughade SN. Oral submucous fibrosis: Study of 1000 cases from central India. J Oral Pathol Med 2007;36:12-7.  Back to cited text no. 11
    
12.
Gupta PC, Ray CS. Smokeless tobacco and health in India and South Asia. Respirology 2003;8:419-31.  Back to cited text no. 12
    
13.
Tilakaratne WM, Klinikowski MF, Saku T, Peters TJ, Warnakulasuriya S. Oral submucous fibrosis: Review on aetiology and pathogenesis. Oral Oncol 2006;42:561-8.  Back to cited text no. 13
    
14.
Pai SA. Gutkha banned in Indian states. Lancet Oncol 2002;3:521.  Back to cited text no. 14
[PUBMED]    
15.
Times News Network. Maharastra bans sale of pan masala. Bangalore: The Times of India; 2012. p. 12.  Back to cited text no. 15
    
16.
Goldenberg D, Lee J, Koch WM, Kim MM, Trink B, Sidransky D, et al. Habitual risk factors for head and neck cancer. Otolaryngol Head Neck Surg 2004;131:986-93.  Back to cited text no. 16
    
17.
Rajendran R, Vijayakumar T, Vasudevan DM. An alternative pathogenetic pathway for oral submucous fibrosis (OSMF). Med Hypotheses 1989;30:35-7.  Back to cited text no. 17
    
18.
Rajalalitha P, Vali S. Molecular pathogenesis of oral submucous fibrosis: A collagen metabolic disorder. J Oral Pathol Med 2005;34:321-8.  Back to cited text no. 18
    
19.
Pillai R, Balaram P, Reddiar KS. Pathogenesis of oral submucous fibrosis. Relationship to risk factors associated with oral cancer. Cancer 1992;69:2011-20.  Back to cited text no. 19
    
20.
Shakya S, Ongole R, Sumanth KN. Copper content of various constituents of betel quid. Indian J Dent Res 2009;20:516-7.  Back to cited text no. 20
[PUBMED]  Medknow Journal  
21.
Pindborg JJ, Sirsat SM. Oral submucous fibrosis. Oral Surg Oral Med Oral Pathol 1966;22:764-79.  Back to cited text no. 21
[PUBMED]    
22.
Chaturvedi P. Gutka or areca nut chewer′s syndrome. Indian J Cancer 2009;46:170-2.  Back to cited text no. 22
[PUBMED]  Medknow Journal  
23.
Smitha B, Donoghue M. Clinical and histopathological evaluation of collagen fiber orientation in patients with oral submucous fibrosis. J Oral Maxillofac Pathol 2011;15:154-60.  Back to cited text no. 23
[PUBMED]  Medknow Journal  
24.
Kerr AR, Warnakulasuriya S, Mighell AJ, Dietrich T, Nasser M, Rimal J, et al. A systematic review of medical interventions for oral submucous fibrosis and future research opportunities. Oral Dis 2011;17:42-57.  Back to cited text no. 24
    
25.
More CB, Das S, Patel H, Adalja C, Kamatchi V, Venkatesh R. Proposed clinical classification for oral submucous fibrosis. Oral Oncol 2012;48:200-2.  Back to cited text no. 25
    
26.
Sheshaprasad R, Hebbar PB, Pai A. Suggested modification for the proposed clinical classification on OSMF. Oral Oncol 2012; Sept 4. Epub ahead of print.  Back to cited text no. 26
    
27.
Angadi PV. Little evidence that current interventions can benefit patients with OSMF. Evid Based Dent 2011;12:43.  Back to cited text no. 27
[PUBMED]    
28.
Anantha N, Nandakumar A, Vishwanath N, Venkatesh T, Pallad YG, Manjunath P, et al. Efficacy of an anti-tobacco community education program in India. Cancer Causes Control 1995;6:119-29.  Back to cited text no. 28
    
29.
Warnakulasuriya S. Squamous cell carcinoma and precursor lesions: Prevention. Periodontol 2000;2011:57:38-50.  Back to cited text no. 29
    
30.
Cox S, Zoellner H. Physiotherapeutic treatment improves oral opening in oral submucous fibrosis. J Oral Pathol Med 2009;38:220-6.  Back to cited text no. 30
    
31.
Patil PG, Patil SP. Novel mouth-exercising device for oral submucous fibrosis. J Prosthodont 2012 Epub ahead of print.  Back to cited text no. 31
    
32.
Jiang X, Hu J. Drug treatment of oral submucous fibrosis: A review of the literature. J Oral Maxillofac Surg 2009;67:1510-5.  Back to cited text no. 32
    
33.
Chole RH, Gondivkar SM, Gadbail AR, Balsaraf S, Chaudhary S, Dhore SV, et al. Review of drug treatment of oral submucous fibrosis. Oral Oncol 2012;48:393-8.  Back to cited text no. 33
    
34.
Kar IB, Sethi AK. A rare ocular complication following treatment of oral submucous fibrosis with steroids. Natl J Maxillofac Surg 2011;2:93-5.  Back to cited text no. 34
[PUBMED]  Medknow Journal  
35.
Mukherjee S, Ray JG, Chaudhuri K. Zinc and vitamin A as a low cost management of oral submucous fibrosis: Comment on Chole RH et al. "Review of drug treatment of oral submucous fibrosis. Oral Oncol 2012;48:e27-8.Epub 2012 Jun 15.  Back to cited text no. 35
[PUBMED]    
36.
Kumar A, Bagewadi A, Keluskar V, Singh M. Efficacy of lycopene in the management of oral submucous fibrosis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007;103:207-13.  Back to cited text no. 36
    
37.
Kerr AR. Efficacy of oral lycopene in the management of oral submucous fibrosis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007;103:214-5.  Back to cited text no. 37
[PUBMED]    
38.
Rajendran R, Rani V, Shaikh S. Pentoxifylline therapy: A new adjunct in the treatment of oral submucous fibrosis. Indian J Dent Res 2006;17:190-8.  Back to cited text no. 38
[PUBMED]  Medknow Journal  
39.
Sharma JK, Gupta AK, Mukhija RD, Nigam P. Clinical experience with the use of peripheral vasodilator in oral disorders. Int J Oral Maxillofac Surg 1987;16:695-9.  Back to cited text no. 39
    
40.
Joshi J, Ghaisas S, Vaidya A, Vaidya R, Kamat DV, Bhagwat AN, et al. Early human safety study of turmeric oil (Curcuma longa oil) administered orally in healthy volunteers. J Assoc Physicians India 2003;51:1055-60.  Back to cited text no. 40
    
41.
Hastak K, Lubri N, Jakhi SD, More C, John A, Ghaisas SD, et al. Effect of turmeric oil and turmeric oleoresin on cytogenetic damage in patients suffering from oral submucous fibrosis. Cancer Lett 1997;116:265-9.  Back to cited text no. 41
    
42.
Routray S, Motgi AS, Sunkavalli A. Comment on "Chole RH et al. Review of drug treatment of oral submucous fibrosis. Oral Oncol 2012;48:e13-4.Epub 2012 Mar 19.  Back to cited text no. 42
[PUBMED]    
43.
Sudarshan R, Annigeri RG, Sree Vijayabala G. Aloe vera in the treatment for oral submucous fibrosis - A preliminary study. J Oral Pathol Med 2012; 41:755-61.  Back to cited text no. 43
    
44.
Khanna JN, Andrade NN. Oral submucous fibrosis: A new concept in surgical management. Report of 100 cases. Int J Oral Maxillofac Surg 1995;24:433-9.  Back to cited text no. 44
    
45.
Borle RM, Nimonkar PV, Rajan R. Extended nasolabial flaps in the management of oral submucous fibrosis. Br J Oral Maxillofac Surg 2009;47:382-5.   Back to cited text no. 45
    
46.
Huang IY, Wu CF, Shen YS, Yang CF, Shieh TY, Hsu HJ, et al. Importance of patient′s cooperation in surgical treatment for oral submucous fibrosis. J Oral Maxillofac Surg 2008;66:699-703.  Back to cited text no. 46
    
47.
Le PV, Gornitsky M, Domanowski G. Oral stent as treatment adjunct for oral submucous fibrosis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1996;81:148-50.  Back to cited text no. 47
    
48.
Patil PG, Parkhedkar RD. New graft-stabilizing clip as a treatment adjunct for oral submucous fibrosis. J Prosthet Dent 2009;102:191-2.  Back to cited text no. 48
    



 
 
    Tables

  [Table 1]

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