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Oral sub-mucous fibrosis is a chronic debilitating disease of the oral cavity characterized by inflammation and progressive fibrosis of the submucosal tissues (lamina propria and deeper connective tissues). Oral sub-mucous fibrosis results in marked rigidity and an eventual inability to open the mouth.
Symptoms of oral sub-mucous fibrosis include the following:
- Progressive inability to open the mouth (trismus) due to oral fibrosis and scarring
- Oral pain and a burning sensation upon consumption of spicy foodstuffs
- Increased salivation
- Change of gustatory sensation
- Hearing loss due to stenosis of the eustachian tubes
- Dryness of the mouth
- Nasal tonality to the voice
- Dysphagia to solids (if the esophagus is involved)
- Impaired mouth movements (e.g, eating, whistling, blowing, sucking)
Oral sub-mucous fibrosis is clinically divided into three stages and the physical findings vary accordingly:
Stomatitis includes erythematous mucosa, vesicles, mucosal ulcers, melanotic mucosal pigmentation, and mucosal petechia.
Fibrosis occurs in ruptured vesicles and ulcers when they heal, which is the hallmark of this stage. Early lesions demonstrate blanching of the oral mucosa.
Older lesions include vertical and circular palpable fibrous bands in the buccal mucosa and around the mouth opening or lips, resulting in a mottled, marblelike appearance of the mucosa because of the vertical, thick, fibrous bands running in a blanching mucosa. Specific findings include the following:
- Reduction of the mouth opening (trismus)
- Stiff and small tongue
- Blanched and leathery floor of the mouth
- Fibrotic and de-pigmented gingiva
- Rubbery soft palate with decreased mobility
- Blanched and atrophic tonsils
- Shrunken budlike uvula
- Sinking of the cheeks, not commensurate with age or nutritional status
Leukoplakia is precancerous and is found in more than 25% of individuals with oral sub-mucous fibrosis.
Speech and hearing deficits may occur because of involvement of the tongue and the eustachian tubes.
Oral dysplasias and squamous cell carcinomas are complications of oral sub-mucous fibrosis. In patients with oral sub-mucous fibrosis, the risk of developing oral carcinoma is 7.6% over a 10-year period.
If the palatal and paratubal muscles are involved in patients with oral sub-mucous fibrosis, conductive hearing loss may occur because of functional stenosis of the eustachian tube.
Patients with oral sub-mucous fibrosis who require anesthesia for trismus correction, resection, and reconstructive (oncoplastic) surgery may have difficulty during laryngoscopy and intubation of the trachea.
Treatment Of Oral Sub-Mucous Fibrosis
The treatment of patients with oral sub-mucous fibrosis depends on the degree of clinical involvement. If the disease is detected at a very early stage, cessation of the habit is sufficient. Most patients with oral sub-mucous fibrosis present with moderate-to-severe disease. Moderate-to-severe oral sub-mucous fibrosis is irreversible. Medical treatment is symptomatic and predominantly aimed at improving mouth movements.
In patients with moderate oral sub-mucous fibrosis, weekly submucosal intralesional injections or topical application of steroids may help prevent further damage.
Anti-oxidant Drug Therapy
Lycopene is considered best antioxidant for the treatment of oral sub-mucous fibrosis.
Surgical treatment is indicated in patients with severe trismus and/or biopsy results revealing dysplastic or neoplastic changes. Surgical modalities that have been used include the following:
Simple Excision Of The Fibrous Bands
Excision can result in contracture of the tissue and exacerbation of the condition.
Split-thickness Skin Grafting Following Bilateral Temporalis Myotomy Or Coronoidectomy
Trismus associated with oral sub-mucous fibrosis may be due to changes in the temporalis tendon secondary to oral sub-mucous fibrosis; therefore, skin grafts may relieve symptoms.
Nasolabial Flaps And Lingual Pedicle Flaps
Surgery to create flaps is performed only in patients with oral sub-mucous fibrosis in whom the tongue is not involved.
Use of a laser release procedure was found to increase mouth opening range in 9 patients over a 12-month follow-up period in one study.
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