Various Treatment Modalities and Visceral Organ Involvement (Cardiac) in Oral Submucous Fibrosis: A Clinical Study

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1 /jp-journals S RESEARCH Manoj Kumar et ARTICLE al Various Treatment Modalities and Visceral Organ Involvement (Cardiac) in Oral Submucous Fibrosis: A Clinical Study 1 S Manoj Kumar, 2 S Shanmugam, 3 M Ramalakshmi, 4 Suman Jaishankar 1 Professor, Department of Oral Medicine and Radiology, Ragas Dental College and Hospital, Chennai, Tamil Nadu, India 2 Professor and Head, Department of Oral Medicine and Radiology, Ragas Dental College and Hospital, Chennai, Tamil Nadu, India 3 Senior Lecturer, Department of Oral Medicine and Radiology, Ragas Dental College and Hospital, Chennai, Tamil Nadu, India 4 Professor, Department of Oral Medicine and Radiology, KSR Institute of Dental Sciences, Tamil Nadu, India Correspondence: S Manoj Kumar, Professor, Department of Oral Medicine and Radiology, 2/102, East Coast Road, Uthandi Chennai , Tamil Nadu, India, smanojk@indiatimes.com ABSTRACT Oral submucous fibrosis (OSMF) is one of the most poorly understood and unsatisfactorily treated disease. In this study, combined treatment modalities were tried based on the grading and staging of OSMF, and outcomes of treatment were noticed. In addition to this, visceral organ involvement evidenced by systemic fibrosis has been assessed to see, if OSMF is a part of systemic spectrum of disease. Keywords: Oral submucous fibrosis (OSMF), Oral mucosal changes, Antioxidants. INTRODUCTION OSMF is a well-known clinical entity since the time of Sushruta when it was known as Vitari. 1 Pindborg and Sirsat (1966) 2 described OSMF as a chronic insidious disease affecting any part of the oral cavity and sometimes the pharynx, although occasionally preceded by and or associated with vesicle formation, it is always associated with a juxta-epithelial inflammatory reaction followed by fibroelastic change of the lamina propria with epithelial atrophy leading to stiffness of oral mucosa and causing trismus and inability to eat. 3 The treatment of OSMF can be medical or surgical. The medical management includes cessation of habits with systemic intake of vitamins, antioxidants and iron supplements, topical application of triamcelone acetonide, intralesional injection of hyaluronidase, hydrocortisone, placental extract, lycopene and interferon gamma. Visceral organ involvement evidenced by systemic fibrosis has not been explored much in OSMF. The investigations in this aspect were limited to locoregional sites of nasopharynx and esophagus. Whether the OSMF is a part of systemic spectrum of disease involving multiple organs is an interesting pursuit. AIMS AND OBJECTIVES The aim of this study was to diagnose and grade OSMF based on clinical finding and to assess the efficacy of combined treatment modality depending upon the grade in terms of clinical and symptomatic improvement and to evaluate cardiac involvement. 190 OBTAINING APPROVAL FROM THE AUTHORITIES Permission from the ethical committee of the government dental college and hospital was obtained before the starting of the study for examination and interpretation of patients. Also, an informed consent was obtained from the patients forming the study sample to participate in the study. MATERIALS AND METHODS This clinical study was carried out in the Department of Oral Medicine and Radiology, Tamil Nadu Dental College and Hospital, Chennai, as well as in the Department of Cardiology, Madras Medical College and Hospital, Chennai. The study consisted of 40 patients suffering from OSMF of various grades who were selected from the Outpatient Department of Oral Medicine and Radiology, Tamil Nadu Dental College and Hospital, Chennai. On the first visit, all the demographic details of the patient were recorded. Routine blood and urine examinations, with a thorough check-up by the physician along with cardiovascular investigation like electrocardiography and echocardiography to rule out endomyocardial fibrosis was done. All the findings were recorded in the preformed proforma. Patients who had known cardiac problems were excluded from the study. The selected patients were clinically divided into various grades based on the clinical grading by Gupta Dinesh Chandra S, Dolas Rameswar and Ali Iqbal (1992). 4 The gradings were slightly modified for the ease of treatment as follows.

2 JIAOMR Various Treatment Modalities and Visceral Organ Involvement (Cardiac) in Oral Submucous Fibrosis: A Clinical Study CLINICAL GRADING Grade I presence of only blanching of oral mucosa without symptoms Grade II presence of blanching and burning sensation, dryness of the mouth, vesicles or ulcers in the mouth Grade III presence of blanching and burning sensation, dryness of the mouth, vesicles or ulcers in the mouth with restricted mouth opening and palpable bands all over the mouth without tongue involvement Grade IV presence of blanching and burning sensation, dryness of the mouth, vesicles or ulcers in the mouth with restricted mouth opening and palpable bands all over the mouth with tongue involvement Grade V presence of all features of grade IV associated with chronic ulcer and histologically proven carcinoma. Grade V cases were not included in the study. The Assessment of Blanching depending on the Color of Mucosa Score 0 normal pink color Score 1 red or deep pink color Score 2 pale white color Score 3 blanched white color As mentioned by Katharia SK and BK Varma (1994). 5 The Assessment of Presence or Absence of Burning Sensation Score 0 no burning sensation Score 1 mild burning sensation Score 2 moderate burning sensation Score 3 severe burning sensation. The Assessment of Interincisal Distance/Mouth Opening Grade I mouth opening 36 mm or above Grade II mouth opening 26 to 35 mm Grade III mouth opening 16 to 25 mm Grade IV mouth opening 6 to 15 mm. The Assessment of Tongue Protrusion Grade I beyond the vermillion border of the lower lip Grade II within the vermillion border of the lower lip Grade III upto the incisal third of the lower mandibular anteriors Grade IV cannot protrude, tongue within floor of the mouth. The cardiovascular assessment for the presence of endomyocardial fibrosis was done, based on the electrocardiography and echocardiography as highlighted by Rajendran R (2001). 6 The selected cases were subjected to various treatment modalities as done by Gupta Dinesh Chandra, Dolas Rameswar and Ali Iqbal (1992). 3 A posttreatment analysis assessment was performed and a follow-up of 6 months was done. Treatment modalities included elimination of oral sepsis by proper oral hygiene methods, elimination of habits, oral prophylaxis and symptomatic treatment. RESULTS The study showed an increased incidence of OSMF in the age group of 19 to 61 years with male predilection. Pan masala and betel nut were equal predisposing factors (32.5% each), duration ranging from 1 to 11 years with 55% smokers, 50% alcoholics. The mean ESR level for males was and females was which was slightly increased. The mean hemoglobin percentage was calculated at which was in a borderline. Posttreatment with various treatment modalities showed improvement in color of oral mucosa, reduction in burning sensation, increased interincisal distance and tongue protrusion (Tables 1 to 3, Graphs 1 to 3). None of the patients had endomyocardial fibrosis. Grades Drug administered Dose Duration Mode Grade I Antioxidant (Tab A to Z) 1 tab once daily 10 weeks Oral Grade II Iron supplement 1 tab once daily 10 weeks Oral (Tab Hemfer) Triamcinalone acetonide 0.1% 4 weeks (grade I) Topical ointment 8 weeks (grade II) Grade III Injection hyaluronidase 1500 IU Biweekly for 10 weeks Intralesionally in (hynidase) combination Grade IV Injection dexamethasone 2 ml Local anesthetic 1 ml 2% without adrenaline Injection placentrix 2 ml Weekly once for 4 weeks Intralesionally (separately) Antioxidant (Tab A to Z) 1 tab once daily 10 weeks Oral Iron supplement 1 tab once daily 10 weeks Oral (Tab Hemfer) Triamcinalone acetonide 0.1% 4 weeks Topical ointment Journal of Indian Academy of Oral Medicine and Radiology, July-September 2011;23(3):

3 S Manoj Kumar et al Table 1: Comparison of pretreatment and posttreatment scores for improvement in color of oral mucosa and burning sensation Score Color of mucosa Burning sensation Significance Number of patients Pretreatment Posttreatment Pretreatment Posttreatment X 2 = p = Table 2: Comparison of pretreatment and posttreatment scores for improvement in interincisal distance Score Pretreatment interincisal Posttreatment interincisal Significance distance distance Mean t = N p = Std deviation Mean t = N p = Std deviation Table 3: Comparison of pretreatment and posttreatment scores for improvement in tongue protrusion Score Pretreatment (number of Posttreatment Significance patients) (number of patients) X 2 = p = Graph 1A: Comparison of pretreatment and posttreatment scores for improvement in color of oral mucosa Graph 1B: Comparison of pretreatment and posttreatment scores for improvement in burning sensation DISCUSSION In our study, there were 40 patients whose age ranged from 19 to 61 years and the mean age was 36.5 years. The affliction of the disease at a younger age group and the third decade of life coincides with the study conducted by Dayal PK et al (1996), 7 Paissat (1981), 8 Gupta Dinesh Chandra et al (1992). 3 Our study had 28 males 70% and 12 females 30% which showed a male predominance which can be correlated to the 192 study conducted by Yuh-Yuan et al, Dayal PK et al (1996) 7, Tubkari JV et al (2007). 9 A total of 32.5% of the patients used betel nuts, 32.5% of the patients used pan masala, 22.5% of the patients used Gutka, 5% of the patients used Zarda and 7.5% of the patients used others which coincides with Dayal PK et al (1996) 7 and JV Tubkari et al (2007). 9 The mean hemoglobin percentage was calculated at which was in a borderline, supports the hypothesis putforth by Ramanathan (1981) 10 that this condition is a Asian version of sideropenic dysphagia

4 JIAOMR Various Treatment Modalities and Visceral Organ Involvement (Cardiac) in Oral Submucous Fibrosis: A Clinical Study Graph 2: Comparison of pretreatment and posttreatment scores for improvement in tongue protrusion Graph 3: Comparison of pretreatment and posttreatment scores for improvement in tongue protrusion wherein iron deficiency leads to mucosal susceptibility to mucosal irritants. In our study, 32 patients who had blanching of oral mucosa before treatment showed marked improvement in the color, evidenced by the change in color and 15 patients who had severe burning sensation before treatment had a moderate burning sensation, evidenced by statistically significant value of X 2 = 80, p = 0.01, which coincides with the study conducted by Balaji Rao (1993), 11 Bailoor DN (1993), 12 Gupta Dinesh Chandra (1992), 3 Ipe Vargese, Hari (1994) 13 and Rajendran R (1994) 14 whose study showed great improvements in clinical symptoms of OSMF. In grade III cases, the mean interincisal distance before treatment was 12 mm and posttreatment was 22 mm. In grade IV cases, the mean interincisal distance before treatment was 17 mm and posttreatment was 28 mm. The average mean increase in mouth opening was 10 mm with a significant p = There were six patients in our study whose tongue was within the vermillion border of the lower lip before treatment which improved in such a way that patient could protrude the tongue beyond the vermillion border of the lower lip. Three patients who could protrude the tongue upto the incisal third of the lower mandibular anteriors before treatment could protrude the tongue upto vermillion border of the lower lip after treatment. The values were significant with X 2 = 20, p = 0.01 which coincides with the study conducted by Kakar PK et al (1985), 15 Balaji Rao (1993), 11 Bailoor DN (1993), 12 Chadurvethi V N (1990), 16 Gupta Dinesh Chandra (1992), 3 Ipe Vargese, Hari (1994) 13 and Rajendran R (1994), 14 Lai DR et al (1995) 17 and Singh et al (1996) 18 who suggested that combined therapy can be used as routine measure for OSMF and it had a better long-term effects and the results were satisfactory. Rajendran R et al (2001) 6 suggested an associated visceral organ involvement evidenced by systemic fibrosis has not been expressed in OSMF. All the 40 patients showed negative report to prove that visceral organ involvement is infrequent in OSMF. Thus, OSMF is a locoregional disease, initiated by local factors and propagated under their influence without systemic involvement. SUMMARY AND CONCLUSION It was observed, statistically proved and concluded that combined therapy employing nutritional and iron supplements with intralesional injection therapy using hyaluronidase, dexamethasone and placentrix in addition to local anesthetic topical gel and topical application of triamcinolone acetonide 0.1% caused a marked improvement in patients signs and symptoms evidenced by improvement in color of oral mucosa, decrease in blanching and decreased severity of burning sensation, increased mouth opening and tongue protrusion. Reduction of occurrence of painful ulcers and vesicles as increased mouth opening, tongue protrusion and reduction of occurrence of painful ulcers and vesicles. Furthermore, OSMF patients have infrequent visceral organ involvement. The limitations were long duration of treatment and difficult followup of patients and high cost of the injections. Some patients had pigmentary changes, increased salivation, dryness of the mouth, dysphagia which could not be correlated, as not much studies were available for comparison. REFERENCES 1. Anand R, Pradhan R. Surgical management of submucous fibrosis. Ind J Dent Res 1994;1(4):3. 2. Pinborg JJ, Sirsat SM. Oral submucous fibrosis. OOO 196;22(6): Shafer WG, Hine MK, Levy BM. A textbook of oral pathology (4th ed). Philadelphia, Saunders. 4. Dinesh Gupta Chandra, et al. Treatment modalities in oral submucous fibrosis. How do they stand today? Study of 600 cases. Ind J Oral and Maxillofacial Surgery 1992;7: Rajendran R. Visceral organ involvement is infrequent in oral submucous fibrosis. IJDR 2001;12(1): Dayal PK, Goginani Subashbabu, Shah Raksha. Oral submucous fibrosis: A field study among betel nut chewers, Karnataka state Dent J:XVI(3): Paissat DK. Oral submucous fibrosis. International J Oral Surgery 10: Journal of Indian Academy of Oral Medicine and Radiology, July-September 2011;23(3):

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