What is Oral Submucous Fibrosis? Its Sign and Symptoms, Causes, Areca Nut, and Conclusion

Oral Submucous Fibrosis (OSF) is the “Premalignant Condition” i.e. condition preceding cancerous condition, that was first described by Schwartz in 1952 as “Atropica idiopathica mucosae oris” in five Indian women from Kenya. Later, on the basis of its histological nature, it came to be known as ‘Oral Submucous Fibrosis‘.

It is a chronic, progressive, scarring disease of oral cavity which gives it marble like appearance.

oral submucous fibrosis

WHO defined OSF as “A slowly progressive disease in which fibrous band form in oral mucosa, ultimately leading to the severe restriction of movement of mouth including the tongue”.

How do you know if you have Oral Submucous Fibrosis?

Since, it is a chronic (illness persisting for a long time or constantly recurring) disorder, it takes a minimum of 2-5 years for patients to show any clinical signs and symptoms. Early symptoms of the disease include:-

  • Burning sensation on eating spicy food.
  • Ulcers in oral cavity
  • Excessive salivation
  • Loss of taste perception and depapillation.
  • Dryness of mouth
  • Reddish or purplish spots on tongue, the labial and buccal mucosa.

If left untreated, the disease progresses towards its advanced stage and shows the following symptoms

  • Difficulty in opening of mouth
  • Formation of white fibrous bands in mouth.
  • Blanching of oral mucosa
  • Pain on swallowing
  • Difficulty in whistling or blowing
  • Impairment of tongue movement
  • Pain in ear
  • Nasal voice
  • shrunken uvula
  • Hearing disturbances due to blockade of eustachian tube.

Reduced Mouth Opening

What causes Oral Submucous fibrosis?

Years of studies revealed that areca nut is the main cause behind OSF among many other agents. Some of these are

  • Chillies
  • Tannic Acid ( present in tea, coffee, wine, grapes etc.)
  • Copper
  • Tobacco
  • Human Papilloma Virus (HPV) infection.
  • Other causes of the disease include genetic abnormalities and nutritional deficiencies.

How Areca Nut Leads to Oral Submucous Fibrosis?

Betel Nuts

Areca nut (Areca catechu) also known as betel nut contain four main alkaloids i.e. arecoline, arecadine, guasine, guacoline which are responsible for this condition. These alkaloids results in abnormal increase in collagen synthesis by fibroblast. Also, they decrease the secretion of collagenase, the enzyme responsible for destruction of collagen. All these factors concomitantly leads to formation of more stable collagen structure, ultimately resulting in fibrosis of oral tissues.

In addition to this, chewing of areca nuts results in release of copper which causes increase in collagen cross-linkage due to upregulation of enzyme lysyl oxidase. According to a study, the level of copper was found to be 5.5-7.5 μg/g in patients with OSF and 4.5-5 μg/g in normal individuals. Along with this, betel quid also affects the immune system of the patient. The levels of transforming growth factor (TGF)-β and interferon (IFN)-γ are lower in mononuclear cells from OSF patients than from other normal individuals. TGF-β is responsible for both procollagen gene activation and decrease in collagenase activity. Both these factors together culminates into formation of fibrous bands in the oral cavity.

Can you get Oral Submucous Fibrosis even without consuming Areca Nuts and other related products?

Although, highest incidence of disease are seen among individuals who have a habit of chewing areca nuts or tobacco but
one can still get the disease due to certain genetic abnormalities. Patients with OSF are found to have raised frequencies of Human Leucocyte Antigens (HLA) A10, -B7 and -DR3 than normal individuals. Various genes involved are

  • TGF-β2
  • SMAD-3
  • Matrix Metalloproteinase (MMP1)
  • MMP2
  • MMP9 etc.

What are the combined effects of Areca Nut and other agents?

Severe studies showed an increase in the incidence of OSF when areca nut and tobacco consumption were consumed simultaneously.
People who consume these mixed products usually belong to younger age group, i.e, 18-30 years of age. In such individuals the progression of disease is far more rapid then other individuals. Usually OSF takes 8-9 years to show its clinical signs and symptoms in patients who consume only betel quid but with consumers of mixed products this time gap is reduced to mere 2-3 years. Along with this, such patients show malignant transformation at a very early age.

Epidemiology

Occurrence of Oral Submucous fibrosis differs with habits, diets and culture among different regions. South and South-East
Asia has the highest prevalence of disease across the globe. People of these nations have increased habits of chewing areca nut
and other related products that lead to OSF. The prevalence of disease varies among different South-Asian countries. Oral Submucous fibrosis is rare in the United States and is found only in the immigrant members of the South Asian population who chew betel nuts.

According to some studies, prevalence of Oral Submucous Fibrosis was reported to be 0.15-14.6% in Vietnam, 0.9-4.7% in China, 0.086-17.6% in Taiwa.

Based on World health organization (WHO) statistics, there are more than 5 million patients of OSF globally. The ages of these
patients range from 20 to 80 years. The disease is more prevalent among females of a population due to various factors such as oral habits, deficiency of vital nutrients like iron and vitamin B complex etc.

Is Oral Submucous Fibrosis Cancer?

Oral Submucous Fibrosis is a premalignant condition, it implies that if an individual is diagnosed with OSF, the risk for cancer in
such an individual increases many folds. According to some studies, 1-1.5% cases of OSF transforms into malignancy, particularly ‘squamous cell carcinoma’.

Is Oral Submucous Fibrosis curable?

Oral Submucous Fibrosis is a chronic disease, if diagnosed at an early stage, cessation of the habit of chewing areca nut is
sufficient. In moderate to severe stages medical intervention is must. For effective treatment of the disease following regimens have been proposed:-

Nutritional Supplements

Nutritional deficiency is one of the important cause of OSF. Such individuals should take supplements of Vitamin A, Vitamin B complex and other minerals.

Physiotherapy

The patients of OSF face major difficulty in opening of mouth. So, they are commonly kept on mouth opening and heat therapy.

Immunomodulatory Drugs

Patients of OSF are administered with steroids to reduce or supress inflammation and fibrosis.

Surgical Management

Surgery is seen as a last resort in OSF and is usually not preferred because incision of fibrous bands might lead to even more fibrosis.

Combined therapy

Nowadays, combination of various steroids, vasodilators and Vitamin supplements along with physiotherapy is preferred as first line of treatment for effective results.

Conclusion

With proper and in time treatment Oral Submucous Fibrosis is completely curable. But one should take proper precautions and should quit all such habits that might culminate into severe problems in future.

References

  • Nektarios I Lountzis, M. D. (2021, May 18). Oral submucous fibrosis. Background, Pathophysiology, Etiology. Retrieved October 23, 2021, from https://emedicine.medscape.com/article/1077241-overview.
  • Oral submucous fibrosis: an update. (2015). PubMed Central (PMC). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4401336/
  • Rao, N. R. (2020, January 8). Oral submucous fibrosis: a contemporary narrative review with a proposed inter-professional approach for an early diagnosis and clinical management. Journal of Otolaryngology – Head & Neck Surgery. https://journalotohns.biomedcentral.com/articles/10.1186/s40463-020-0399-7

Dr Deepak Kansal

Dr Deepak Kansal is a dentist, who is currently working in Sri Ganganagar. He did his Bachelor of Dental Surgery from Rajasthan University of Health Science.

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