oral sub-mucous fibrosis : a precancerous lesion

1

Oral Submucous Fibrosis: A Precancerous Lesion

Sabrina_Abbas_49DDCH_2017

Sabrina_Abbas_49DDCH_2017 2

Presenters:Dr.Sabrina Farida Chowdhury

Dr.Shanjida Wasima Raka

Sabrina_Abbas_49DDCH_2017 3

Precancerous Lesion:A generalized state associated with a significantly increased risk of cancer

Sabrina_Abbas_49DDCH_2017 4

Premalignant Lesions:• Leukoplakia(Dysplastic or Speckled)• Erythroplasia• Tertiary syphillis• Oral submucous fibrosis• Chronic candidosis• Lichen planus• Pipe smoker keratosis

Sabrina_Abbas_49DDCH_2017 5

Erythroplasia Oral submucous fibrosis

Dysplastic Leukoplakia Tertiary syphillis

High Risk for Malignant Change

Sabrina_Abbas_49DDCH_2017 6

Oral Submucous Fibrosis:

It is a chronic progressive scarring disease in which oral mucosa becomes fibroric, immobile and contracts progressively causing limitation of opening of mouth.• It is predominantly seen in people of Asian descent• Malignanttransformation rate for osmf is 7 to 13 parcent

Sabrina_Abbas_49DDCH_2017 7

Aetiological factors :• Chewing betel nut, betel leaf

Sabrina_Abbas_49DDCH_2017 8

-Panmasala

- Vitamin D deficiency -Protein Deficiency - Alcohol

Sabrina_Abbas_49DDCH_2017 9

Site:OSMF affects most part of oral cavity,pharynx and upper third of the esophagus

Sabrina_Abbas_49DDCH_2017 10

Pathogenesis: Oral Mucosa

Betel Quid

Constant Irritation

Chronic Inflammation

Activated T cell and macrophages at the site

Increase in cytokines IL6,TNF,increase in growth factor TGF beta

Sabrina_Abbas_49DDCH_2017 11

Increase in Collagen production

Decrease in collagen degradation

Increased collagen(insoluble cross0linking of insoluble form of collagen)

Fibrosis

Oral Submucous Fibrosis

Sabrina_Abbas_49DDCH_2017 12

Clinical Features:-Symmetrical fibrosis develops in buccal mucosa,soft palate or inner aspect of lips.-fibrosis occur and results in extreme pallor-the fibrous bands are pale-white in colour and palpable mostly-limited mouth opening-intolerance to spicy food-Hearing loss due to stenosis of Eustachian tube

Sabrina_Abbas_49DDCH_2017 13

StagingOral submucous fibrosis is clinically divided into three stages:• Stage 1: Stomatitis• Stage 2: Fibrosis• a- Early lesions, blanching of the oral mucosa• b- Older lesions, vertical and circular palpable fibrous bands in and

around the mouth or lips, resulting in a mottled, marble-like appearance of the buccal mucosa

• Stage 3: Sequelae of oral submucous fibrosis• a- Leukoplakia• b- Speech and hearing deficits

Sabrina_Abbas_49DDCH_2017 14

Group Classification:

• Group 1: Earliest stage, no limitation in mouth opening and interimcisal distance is greater than 35mm• Group 2:Interincisal distance is of 26-35mm• Group 3:Moderately advanced case with Interincisal distance of 15-

25mm• Group 4A:Trismus is more severe,interincisal distance is less than

15mm and there is extensive fibrosis of all oral mucosa• Group 4B:more advanced withpremalignant or malignant change

Sabrina_Abbas_49DDCH_2017 15

Treatment

• Conservative Trearment:Motivation and Counseling:-Assurance-Proper education regarding this disease to be given to the patient-encourage to discontinue the habit of chewing betel nut/leaf.-minimizing consumption of spicy foods

Sabrina_Abbas_49DDCH_2017 16

Supportive care:-Vitamin,iron and mineral diets to be adviced to the patient with OSMF-maintaining proper oral hygiene

Medical Managemnt:1.Interlesional steroid

Sabrina_Abbas_49DDCH_2017 17

2.Hyaluronidase injection3.Combination of both steroid and hyaluronidase has shown better long term result than the agent alone(0.5 ml intralesional injection of Hyaluronidase 1500 IU and 0.5 ml of injection Hydrocortisone acetate 25 mg/ml in each buccal mucosa once a week alternatively for 4 weeks or more as per condition)4.Placental Extracts5.Chymotrypsin6.Interferon Gamma7.Immune Milk

Sabrina_Abbas_49DDCH_2017 18

Oral Physiotherapy:-Muscle stretching exercises

-forceful opening of mouth by sticks ballooning of mouth,hot water gargling

-forceful mouth opening with mouth gag and acrylic surgical screw

Sabrina_Abbas_49DDCH_2017 19

Surgical Intervention:In the trismus group stage 3 and stage 4-• -Wide surgical exicision of the affected tissues

including the underlying buccinators muscle together with skin grafting can be carried out• Release of the fibrous band with temporalis muscle

myotomy may be perfomed/

Sabrina_Abbas_49DDCH_2017 20

A Case Report on- Oral Submucous Fibrosis (Group 2)

Sabrina_Abbas_49DDCH_2017 21

A 48 years old lady with the complaints of limited mouth opening and burning sensation while having spicy food visited the Oral and Maxillofacial department,Dhaka Dental College and Hospital.

Sabrina_Abbas_49DDCH_2017 22

Patient’s Profile:Name:Monju DasAge:48yearsSex:FemaleOccupation:Home makerReligion:Hinduism

Sabrina_Abbas_49DDCH_2017 23

Chief Complaints:

• Whitish lesion in inner cheek and palate for 8-9months• Restricted mouth opening since 4-5 months• Burning sensation while taking spicy foods

Sabrina_Abbas_49DDCH_2017 24

Clinical Examination:

• History of Present illness:According to the statement of the patient,she was reasonable well 9 months back.Then she developed whitish lesion on both sided buccal mucosa,retromolar area and palate.Initially there was no pain or any other difficulty.But later she started experiencing limited mouth opening along with burning sensation while spicy food intake.

Sabrina_Abbas_49DDCH_2017 25

• History of past illness-Nothing associated with this condition

Personal History:History of Habit of chewing betel nut with leaf for last 20yearsFrequency:8/9 times/day

Sabrina_Abbas_49DDCH_2017 26

Family History:She has two sons.There is no significant familial history associated with current condition

Drug/Allergy history:N/C

Socio-economic status:She belongs to a middle class family.

Immunization History:immunized per EPI scheduel

Sabrina_Abbas_49DDCH_2017 27

General examination:Appearance:Ill lookingBody Built:AverageCo-operation:Co-operativeDecubitus :On choiceAnaemia:AbsentJaundice:AbsentPulse:76 beats/minBlood Pressure:12o/85mm hgrespiratory rate:18 breaths/min

Sabrina_Abbas_49DDCH_2017 28

Local ExaminationExtraoral Examination:• Appearance:Anxious• Lip:Competent• Limited mouth opening -28mm

Sabrina_Abbas_49DDCH_2017 29

Intraoral Examination:Inspection:-Blanched white pale mucosal lesion extending from buccal mucosa to the retromolar area on both side involving the soft palate-stained teeth-gingival recession

Sabrina_Abbas_49DDCH_2017 30

Palpation:Fibrous band were palpable on the both side

Measuring the mouth opening:28mm

Sabrina_Abbas_49DDCH_2017 31

Diagnosis:

•  No laboratory tests can confirm the presence of this pre-cancerous condition.• However, some recent researches show that OSF patients are

likely to have decreased hemoglobin, iron, protein and vitamin B complex levels in the blood. The erythrocyte sedimentation rate is also believed to increase in these patients.• At present, modern diagnostic tools like ultrasonography and x-ray

are being used

Sabrina_Abbas_49DDCH_2017 32

Diagnosis:upon clinical finding and history,the case was diagnosed as Oral submucous fibrosis group 2.

Sabrina_Abbas_49DDCH_2017 33

Treatment:-Adviced to discontinue habit of chewing betel nut/betel leaf

-Adviced to avoid hard and spicy food

-medical Management:Inject. Interlesional steroid at the lesion site

-instruction of proper oral hygiene maintainance

-supportive treatment:vitamin,iron was prescribed.

-adviced to perform facial exercises

Sabrina_Abbas_49DDCH_2017 34

First Day15/02/2017

Sabrina_Abbas_49DDCH_2017 35

Sabrina_Abbas_49DDCH_2017 36

Sabrina_Abbas_49DDCH_2017 37

Mouth opening-28mm

Sabrina_Abbas_49DDCH_2017 38

Sabrina_Abbas_49DDCH_2017 39

Second Day22-02-2017

Sabrina_Abbas_49DDCH_2017 40

Mouth Opening-29mm

Sabrina_Abbas_49DDCH_2017 41

Third visit01-03-2017

Mouth opening:29.5 mmFourth visit09-03-2017

Mouth opening:31mm

Sabrina_Abbas_49DDCH_2017 42

Fifth Visit16-03-2017

Sabrina_Abbas_49DDCH_2017 43

Sabrina_Abbas_49DDCH_2017 44

Sabrina_Abbas_49DDCH_2017 45

Mouth opening:34mm

Sabrina_Abbas_49DDCH_2017 46

Sabrina_Abbas_49DDCH_2017 47

Sabrina_Abbas_49DDCH_2017 48