Do You Have Thick White Bands Inside Your Cheeks?

DONOT IGNORE PLEASE!

Globally Oral Cancer is the sixth most common cause of death with India. Oral habits like tobacco chewing in the form of betel quid areca nut, smoking and alcohol consumption are most prevalent in Indian population. India accounts for 86% of the world’s oral cancer cases.

Chronic tobacco quid consumption (betel quid chewing or areca nuts) results in a progressive premalignant condition called Oral Submucous Fibrosis (OSMF). The hyalinaisation of the buccal mucosa forming white bands on the inner surface of cheeks and decrease in mouth opening is the first symptom followed by burning sensation while taking food and also difficulty in swallowing. Free radicals released during the metabolism of tobacco and areca nut may involve in the initiation and propagation of mucosal fibrosis. The disease predominantly affects people of South-East Asian origin.

Oral Submucous Fibrosis (OSMF) is an extremely discomforting oral condition that is marked by the development of painful lesions inside the mouth that refuse to go away on their own.

This is a highly potent, insidious and chronic pre-cancerous condition that affects various portions of the oral cavity as well as the pharynx. It is a collagen related disorder associated with betel quid chewing and characterized by progressive hyalinization of the submucosa. It causes progressive fibrosis of submucosal tissues and juxta-epithelial inflammatory reactions.

This disabling disease also leads to fibro-elastic changes in the lamina propria along with epithelial atrophy, which results in stiffness of the oral mucosa. It may become impossible to open to the mouth due to the extreme stiffness of the jaw. It manifests as blanching and stiffness of the oral mucosa, progressive trismus due to rigid lips, cheeks and pharynx, burning sensation in the mouth, reduced mobility of the soft palate and tongue, loss of gustatory sensation, intolerance to eating hot and spicy foods and occasionally, mild hearing loss due to blockage of Eustachian tube.

The condition is found in as many as 5 million young Indians who are suffering from this precancerous condition as a result of the increased popularity of the habit of chewing pan masala. Pan masala is a mixture of spices including, betel nuts, catechu, menthol, cardamom, lime and others.  It has a mild stimulating effect and is often eaten at the end of the meal to help digest food and as a breath mint.

Causes of OSMF

The factors that have been discussed as possible causative factors are-

• Hard chewable substances, mainly betel nuts or areca nuts (areca catechu), have various substances that harm the oral mucosa and destroys its elasticity.
• Mouth freshners containing betel nut may also irritate the mucosa if consumed in large amounts.
• Other causes of this disorder include: capsaicin in chillies, hypersensitivity and additionally micronutrient deficiencies of iron, zinc and essential vitamins make it more vulnerable to the effects of carcinogens. A possible autoimmune basis to the disease with demonstration of various auto-antibodies and genetic predisposition with specific human leukocyte antigen (HLA) has also been proposed. Genetic predisposition can further render the oral mucosa more susceptible to chronic inflammatory changes on exposure to carcinogens derived from betel quid components including tobacco. However, the carcinogenic agents associated with the regular use of areca nut/betel nut are the major etiological factor.

Osmf is as serious disease. Early diagnosis and timely treatment can cure it completely, allowing patients to have normal oral movements. However, if left untreated, it can lead to serious health conditions such as oral cancer. Thus in dental clinics in Delhi, the dentists make sure they point it out as soon as they diagnose it. Dentist in Delhi, counsel patients on this condition and this motivated the patients to discontinue their habits.

Clinical features

OSMF is preceded by symptoms such as burning sensation of the oral mucosa, ulceration and pain. The initial stage of osmf is characterized by loss of pigmentation of oral mucosa, leathery texture and blanching of oral mucosa, depapillation and reduced movement of tongue, progressive reduction of mouth opening and sunken cheeks. The changes of OSMF are similar to those of systemic sclerosis (scleroderma) but are limited to oral tissue.

In the more advanced stage of the disease, the mucosa loses its elasticity and becomes stiff and blanched. The essential feature is a fibrous band restricting mouth opening and causing difficulty in mastication, speech, swallowing and maintaining oral hygiene.

This condition is thought to arise in the back of the mouth and gradually spread towards the outer parts. Some of its clinical features include the following-

• Incapability of opening the mouth or decreased mouth opening because of oral fibrosis
• Change of taste and dryness of mouth
• Earache and loss of hearing, due to stenosis of Eustachian tubes
• Nasal intonation of voice
• Recurrent ulceration
• Increased salivation
• Soft palate and faucial pillars showing redness
• Reduced movement of soft palate
• Soft palate showing blanching and shrunken uvula seen in the posterior part
• Small tongue and blanching seen on the  surface of tongue, floor of mouth and restricted movements of tongue
• Stiffening and thinning of the lips

Reduced mouth opening Fibrous bands on inner surface of cheeks Soft palate and faucial pillars showing redness

Treatment

There are many treatment options for oral submucous fibrosis which are mainly decided by the dentist depending on the stage of osmf.

The main and first step which is being stressed in dental clinics in India in getting osmf successfully treated is asking the patient to stop areca nuts chewing in the form of pan/gutka/jarda/beetle nut /smoking/tobacco chewing/ alcohol and eating less spicy food, maintaining oral hygiene and following a diet that contains plenty of iron, vitamin A,B complex as well as C rich foods.

And most important only after stopping the habit, dentists in India advise the following treatments   to resolve the condition.

• Steroid injections- Steroid injections (dexamethasone,betamethasone) are given directly on the affected region to primarily decrease the inflammatory process going on in the lesion.
• Placental extracts- These are human placental extracts which have similar effects as steroids of giving anti-inflammatory effect and causing cessation and stopping progress of the lesion. Placental extracts along with steroids and local anaesthesia is given to give better effect.
• Hyaluronidase- This is an enzyme which degrades/breakdowns hyaluronic acid which in osmf help in decreasing the hyaline bands and in turn helping in increasing elasticity of mucosa and when given along with steroids along with physiotherapy leads to better results and increases mouth opening quickly.
• Lycopene- It is an antioxidant which is mostly useful in improving healing and when given as an oral supplement in osmf patients along with steroid therapy has found increased rate of healing and better results compared to patients only on steroid therapy. Lycopene oral capsules in combination with beta carotene, selenium etc are given only on daily basis to aid treatment of osmf.
• Physiotherapy- Physiotherapy for osmf is a very important part of the treatment procedure as it helps in improving range of mouth opening. This includes measures such as forceful mouth opening, blowing and heat therapy. Jaw dilators exercises explained to the patients to be taken every day. It is mainly important in post surgical cases as the hyaline bands are excised and with physiotherapy the contraction of bands can be prevented.
• Surgical treatment- Surgery may be required if the fibrosis continues to progress despite all the above treatments and the mouth opening gets below 2cm. various surgical treatment options adopted for remedying this condition include simple excision of fibrous bands and creating lingual pedicle and naasiolabial flaps.
• Laser treatment- It is a latest option used for curing osmf. According to a recent study, laser release process has been successful in increasing the opening range of the mouth in several patients over a twelve month follow up period.
• Stem cell therapy- Recent studies have proved the effectiveness and safety of intra-lesional injectional of the autologous stem cells of bone marrow for treating osmf. Studies show that this injection stimulates angiogenesis in the affected area, which reduces the degree of fibrosis. This significantly increases the opening range of the mouth.

Prognosis

With the use of proper treatment, the prognosis or outcome of the disorder is positive in most patients. Osmf can be cured completely when treated at an early stage. This is what dentist in Delhi have been trying to advise patients on. There has been a marked improvement in the prognosis of this condition in dental clinics in Delhi as well as dental clinics in India.

Prevention

Osmf is a completely preventable disorder. As the osmf is a progressive disease, an important step to avoid progression of osmf is to stop the habit completely. Avoiding chewing betel nuts as well as mouth freshners containing this eatable significantly reduces the chances of developing osmf. One should also limit the amount of chillies consumed. Having plenty of chillies may damage the oral mucosa and lead to this disorder. Counselling by the dentists in India to these patients helps a lot.

Posted By – Dr. Suprriya B. Bhatia