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Year : 2012  |  Volume : 30  |  Issue : 1  |  Page : 85-88

Oral submucous fibrosis: A report of two pediatric cases and a brief review

1 Department of Oral Pathology, M. M. C. D. S. R., Mullana, Ambala, Haryana, India
2 Department of Oral Pathology, Dr. R. Ahmed Dental College and Hospital, Kolkata, West Bengal, India
3 Department of Oral Pathology, M. G. M. Dental College and Hospital, Navi Mumbai, Maharashtra, India

Date of Web Publication3-May-2012

Correspondence Address:
R Dhariwal
Department of Oral Pathology, M. M. C. D. S. R., Mullana, Ambala, Haryana - 133 001
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0970-4388.95592

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Oral submucous fibrosis is a chronic debilitating disorder which is usually seen in adults with areca nut chewing habit. A rapid upsurge in the popularity of commercial areca nut products, especially among the younger generation, is a cause of grave concern, as satisfactory management is still lacking. Hereby, two pediatric cases of oral submucous fibrosis are reported.

Keywords: Areca nut, malignant transformation, oral submucous fibrosis, vitamin a, zinc acetate

How to cite this article:
Dhariwal R, Ray J G, Pattanayak S, Swain N. Oral submucous fibrosis: A report of two pediatric cases and a brief review. J Indian Soc Pedod Prev Dent 2012;30:85-8

How to cite this URL:
Dhariwal R, Ray J G, Pattanayak S, Swain N. Oral submucous fibrosis: A report of two pediatric cases and a brief review. J Indian Soc Pedod Prev Dent [serial online] 2012 [cited 2022 Sep 26];30:85-8. Available from: http://www.jisppd.com/text.asp?2012/30/1/85/95592

   Introduction Top

Oral submucous fibrosis (OSMF) is a chronic disorder characterized by progressive fibrosis of the lining mucosa of the upper digestive tract involving the oral cavity, oropharynx, and frequently the upper third of the esophagus, resulting in intolerance to spicy foods, a burning sensation in the mouth, xerostomia, and limitation of mouth opening, tongue mobility, swallowing, or phonation. [1]

It mostly occurs in Asian countries, where chewing betel quid (BQ; contains areca nut, tobacco, slaked lime, or other spices) and other commercial preparations of areca nut in attractive pouches is popular. [2] Epidemiologic surveys in India show the rate of prevalence to be about 0.5%. Persons between 20 and 40 years of age are most commonly affected, with a female: male ratio of 3:1. [3],[4],[5] Morbidity of OSMF among BQ users is about 3.2% [2],[6] and it has a malignant transformation rate in the range of 7-13%. [7]

Histologically, OSMF shows the characteristic features of juxta-epithelial fibrosis, mostly along with atrophy of the overlying epithelium, accumulation of hyalinized collagen beneath the basement membrane, and a progressive loss of vascularity. [7]

The pathogenesis of the disease is not well established, but is believed to be multifactorial. Various mechanisms suggested include: 1) clonal selection of fibroblasts with a high amount of collagen production during long-term exposure to areca nut, [2] 2) stabilization of collagen structure by catechin and tannins from BQ, 3) production of stable collagen (type I) by OSF fibroblasts, 4) increase in collagen cross-linking by up-regulation of lysyl oxidase, 5) deficient collagen phagocytosis, and 6) micronutrient and vitamin deficiencies. [8]

Mainly adults are affected and it is uncommon in the pediatric age group. Only limited number of pediatric cases have been reported in the literature. [3],[4],[5],[9],[10] A youngest case of 4-year-old girl has been reported in the literature. [3] Hereby, two cases of OSMF are reported, highlighting the potential danger of involvement of the pediatric age group from "Pouch Culture."

   Case Reports Top

Case 1

A 10-year-old local factory worker boy reported with difficulty in opening mouth and taking spicy food for the last 3 months. Both his parents were laborers. He was reportedly chewing gutkha two to three times a day for the last 1 year, as his colleagues at the local factory encouraged him to take the habit. On examination, reduced inter-incisal distance (IID=1.5 cm), and generalized blanched oral mucosa involving the soft palate and the anterior faucial pillars were observed [Figure 1] and [Figure 2]. On palpation, loss of normal resilience and pliability of the mucosa with dense fibrotic bands were observed in the buccal mucosa bilaterally. Routine hematological investigations were within the normal range except for the hemoglobin which was 9.1 gm%. A clinical diagnosis of OSMF was confirmed and the boy was prescribed oral iron supplementations, vitamin A, and zinc acetate after counseling to completely quit the habit, but unfortunately the patient failed to report for further follow-up.
Figure 1: Intraoral view showing difficulty in mouth opening with blanching of oral mucosa, generalized stains

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Figure 2: Inter-incisal distance=1.5 mm

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Case 2

A 12-year-old girl complained of burning sensation on having food for the last 3-4 years, which has aggravated recently. The girl's grandmother was a habitual pan masala chewer and unaware of the consequences, used to give her granddaughter a small amount of it almost daily since she was 5 years old. General physical examination revealed normal general condition.

On oral examination, generalized blanched mucosa was observed with loss of elasticity and presence of vertical fibrous bands bilaterally in the buccal mucosa. The uvula was shrunken and the tongue was atrophic. Few retained deciduous root stumps and generalized tobacco stains were observed on dental hard tissue examination [Figure 3]. The IID was 1.9 cm [Figure 4]. Routine hematological examination revealed nothing significant. A diagnosis of OSMF was established. Following the conservative line of treatment, biopsy was considered unnecessary as it adds to the discomfort for patient. Rebound fibrosis has also been reported in certain cases. The girl and her guardians were motivated to completely stop the habit and avoid spicy food. Oral prophylaxis and extraction of the retained root stumps was advised.
Figure 3: Shrunken uvula and generalized blanched mucosa

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Figure 4: Pre-supplementation inter-incisal distance=1.9 mm

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The patient was administered vitamin A (25,000 IU OD) and zinc acetate syrup (5 ml bid) for 3 months. Warm saline rinses and mild mouth-opening exercises were advised along with regular check-up after 15 days followed by 1 month interval.

A relief from burning sensation was reported on the first recall visit itself, i.e. after 15 days. Mouth opening also improved slowly, and after the 3 months regimen, the IID was reported to be 2.5 cm [Figure 5]. Only mild improvement was noticed in the blanching of the oral mucosa. The patient was further advised vitamin B complex supplements every alternate day for the next one month along with warm saline rinses and is under regular follow-up.
Figure 5: Post-supplementation inter-incisal distance=2.4 mm

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   Discussion Top

OSMF is regarded as a collagen metabolic disorder with an overall increased collagen production and decreased collagen degradation resulting in increased collagen deposition in the oral tissues, and fibrosis due to alkaloid exposure. [11]

The list of treatment modalities is extensive and includes the use of micronutrients and minerals, CO2 laser, pentoxifylline, lycopene, interferon gamma, turmeric, hyalase, chymotrypsin, and placental extracts. As fibrosis cannot be reversed when mouth opening is severely reduced, surgical interventions such as myotomy, coronoidectomy, and excision of the fibrotic bands have also been reported in the literature. Alternatively, procedures such as insertion of stent, physiotherapy, local heat therapy, and mouth-opening exercises with acrylic carrots and ice-cream sticks have been tried with variable success rates. [11],[12]

Till today, no well-established treatment for OSMF exists and approaches using injections of steroids, chymotrypsin, hyaluronidase, or alcohol, and surgery using mucosal or non-vascularized split thickness grafts have not only been ineffective but have also often exacerbated the condition, with added scar tissue. [13],[14]

Copper plays a pivotal role in the pathogenesis of OSMF. Copper released in high amounts from areca nut has been reported to up-regulate the enzyme lysyl oxidase in OSMF cases as copper is a ligand for the enzyme. [15] Zinc is an essential component of a large number of enzymes participating in the synthesis of carbohydrates, lipids, proteins, and nucleic acids, and also plays a central role in humoral and cellular immune system. [16] Further, Di Silvestro et al. had reported that higher levels of dietary zinc reduce the bioavailability of copper at absorption stage. [17] Vitamin A is an essential nutrient needed in small amounts by humans for normal functioning of the visual systems, growth and development, maintenance of epithelial integrity, and immune functions. [18] So, based on the previous studies and our own institutional experience, a 3-month regimen of vitamin A and zinc acetate was prescribed with cessation of the habit and regular check-up. [19],[20] Improvement in burning sensation and an increase in mouth opening were observed after 3 months.

To conclude, the present drug treatments are empirical and symptomatic in nature. A combination of several drugs may play an important role in the treatment because it is a multifactorial disease. In the near future, younger ones may be affected more and an active preventive approach is required to limit the morbidity associated with the modern pouch culture.

   References Top

1.Rajendran R. Oral submucous fibrosis-etiology, pathogenesis and future research. Bull World Health Organ 1994;72:985-96.  Back to cited text no. 1
2.Trivedy CR, Craig G, Warnakulasuriya S. The oral health consequences of chewing areca nut. Addict Biol 2002;7:115-25.  Back to cited text no. 2
3.Hayes PA. Oral submucous fibrosis in a 4- year -old girl. Oral Surg Oral Med Oral Pathol 1985;59:475-8.  Back to cited text no. 3
4.Shah B, Lewis MA, Bedi R. Oral submucous fibrosis in a 11-year-old Bangladeshi girl living in the United Kingdom. Br Dent J 2001;191:130-2.  Back to cited text no. 4
5.Mundra RK, Gupta SK, Gupta Y. Oral submucous fibrosis in Paediatric age group., lJO and HNS 1999;51:60-2.  Back to cited text no. 5
6.Jiang X, Hu J. Drug treatment of oral submucous fibrosis: A review of the literature. J Oral Maxillofac Surg 2009;67:1510-5.  Back to cited text no. 6
7.Pindborg JJ, Chawla TN, Srivastava AN. Epithelial changes in oral submucous fibrosis. Acta Odontol Scand 1965;23:277-86.  Back to cited text no. 7
8.Tilakaratne WM, Klinikowski MF, Saku T. Oral submucous fibrosis: Review on aetiology and pathogenesis. Oral Oncol 2006;42:561.  Back to cited text no. 8
9.Anil S, Beena VT. Oral submucous fibrosis in a 12-year-old girl: Case report. Pediatr Dent 1993;15:120-2.  Back to cited text no. 9
10.Yusuf H, Yong SL. Oral submucous fibrosis in a 12-year-old Bangladeshi boy: A case report and review of literature. Int J Paediatr Dent 2002;12:271-6.  Back to cited text no. 10
11.Dyavanagoudar SN. Oral Submucous Fibrosis: Review on Etiopathogenesis. J Cancer Sci and Ther 2009;1:72-7.  Back to cited text no. 11
12.Jiang X, Hu. Drug treatment of oral submucous fibrosis: A review of literature. J Oral Maxillofac Surg 2009;67:1510-5.  Back to cited text no. 12
13.Marx RE, Stern D. Oral and Maxillofacial Pathology. A rationale for diagnosis and treatment. 1 st ed. Quintessence Publishing, Illinois 2003. p. 317-9.  Back to cited text no. 13
14.Fedorowicz Z, Chan Shh-Yen E, Dorri M, Nasser M, Newton T, Shi L. Lack of reliable evidence for oral submucous fibrosis treatments. Evid Based Dent 2009;10:8.  Back to cited text no. 14
15.Trivedy C, Baldwin D, Warnakulasuria S, Johson N, Peters T. Copper content in areca nut products and oral submucous fibrosis. Lancet 1997;349:1447.  Back to cited text no. 15
16.World health organisation. Vitamin and mineral requirements in human nutrition. 2 nd ed. WHO Press, Geneva 2004. p. 230-44.  Back to cited text no. 16
17.Zinc and copper: Evidence for interdependence, not antagonism. Nutrition 2001;17:734-42.  Back to cited text no. 17
18.World health organisation. Vitamin and mineral requirements in human nutrition. 2 nd ed. WHO Press, Geneva 2004. p. 17-37.  Back to cited text no. 18
19.Kumar A, Sharma SC, Sharma P. Beneficial effect of oral zinc in the treatment of oral submucous fibrosis. Indian J Pharmacol 1991;23:236.  Back to cited text no. 19
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20.Dhariwal R, Mukherjee S, Pattanayak S, Chakraborty A, Ray JG, Chaudhuri K. Zinc and vitamin A can minimize the severity of Oral submucous fibrosis. Br Med J Case Rep 2010;doi:10.1136/bcr.10.2009.2348.  Back to cited text no. 20


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]

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