•Chronic disease of Oral cavity / Pharynx / Esophagus

•Preceded by vesicle formation

•Associated with juxta-epithelial inflammatory reaction

•Fibro-elastic changes of the lamina propria, epithelial

Atrophy stiffness of the oral mucosa

•Causing Trismus

•PINDBORG / SIRSAT (1966)

• Shushrutha (600 B.C) - Vidari

• Schwartz (1952) - Atrophia idiopathica (tropica) Mucosae

Oris

• SG Joshi (1953) - “Oral sub-mucous fibrosis”.

• Su PI (1954) - "Idiopathic Scleroderma of mouth”

• Paymaster (1956) – Pre-Malignant

• SE Asia / India

• 0.2 – 0.5 % Prevalence

• 2nd to 4th decade

• M > F (2.3:1) ???? F > M (3:1)

• Malignant Transformation @ 7.6%

CHRONIC IRRITATION Red Chilies (CAPSAICIN)

Betel Leaf (TANNIC ACID)

Slaked Lime Tobacco

(N-NITROSONORNICOTINE) Areca Nut (ARECOLINE / ARECADINE GUVACOLINE / GUVACINE ISOGUVACINE)

NUTRITIONAL DEFICIENCY (B12 / Fe)

INFECTIONS (Bacterial)

CONNECTIVE TISSUE DISEASE (SSc / RA)

INHERITED (HLA-A10 / B7)

MULTIFACTORIAL PATHOGENESIS

ARECANUT TOBACCO LIME VOLATILE OILSVOLATILE LIQUIDS

TANNIN& AFLOTOXIN

ARECOLINE

DEGRADATIONOF COLLAGEN

INCREASED SYNTHESIS OF COLLAGEN

MECHANICAL TRAUMA

CHEMICAL BURN HYPERSENSITIVITY

ALTERED IMMUNITYGENETIC

REDISPOSITION

FIBROBLAST FORMATION

IRREVERSIBLE FIBROSIS

CARCINOMAEXPOSURE CONTINOUS

GRADING (JV Desa 1957 <R> Pindborg (1989)

Stage I : Stage of stomatitis , Vesiculation,

Hyperpigmentation and mucosal petechiae

Burning sensation in the mouth

Inability to eat spicy food

Reduced Mouth Opening

Sunken Cheeks / Malar Prominence

Vesicles rupture Superficial ulcers

Stage ll : Stage of fibrosis

(A) EARLY - blanching or Oral Mucosa

(B) LATE - b- Older lesions, vertical /circular

palpable fibrous bands in and around the

mouth or lips mottled, marble-like

appearance of the buccal mucosa

Stage III : Stage of sequelae / Complications (A) Leukoplakia (25%)

(B) Speech / Hearing Defects

Group I: No mouth opening limitations with an interincisal distance (IID) > 35mm

Group II: IID 26-35 mm

Group III: Moderately advanced case IID 15-26 mm + Fibrotic bands at Soft palate

Group IVA: Trismus is severe, IID < 15mm and extensive fibrosis of all the oral mucosa

Group IVB: Disease is most advanced, with premalignant and malignant changes throughout the mucosa

Oral White Lesions

CandidiasisOral LPRASWhite Sponge NevusMorsicatio Buccarum / LinguarumLinea AlbaLeukoplakia

INTRA-ARTICULAR

Internal derangement of TMJ / meniscus displacement

Fracture / TMJ Disloc

Traumatic synovitis

Arthritis (Septic / OA / Inflamm)

Ankylosis

Acute infections of the oral tissues(Odontogenic infection / Quinsy / Mumps)

Tetanus

Local Malignancy

Systemic sclerosis

Drug associated dyskinesia

Psychotic disturbances, hysteria

INVESTIGATIONS

Increased ESR

Anemia

High eosinophil count

Hypergammaglobulinaemia

Lower serum vitamin A levels

HISTOPATHOLOGY

Atrophic Oral epithelium

Loss of rete pegs

Epithelial atypia

Hyalinization of collagen

Fibroblasts decreased

Blood vessels obliterated

MANAGEMENT

1. Behavioral therapy

2. Medicial therapy

3. Surgical therapy

4. Oral Physiotherapy

Behavioral Therapy

RESTRICTION : Betel Quid / Guthka / Pan

Masala / Chillies ; Counselling regarding

Malignant potential

Other irritants should be removed

Nutritional supplements

Diet

MEDICAL THERAPY

• Hyaluronidase (IL)

• Steroids (topical / IL)

• Placental Extract (topical)

• IFN – Gamma

• Lycopene 16mg/day Oral

• Pentoxifylline 400mg TDS Oral

• Fluorouracil (topical)

• Levamisole 150mg OD for 3 weeks

• Dapsone 75 mg daily X 90 days

SURGICAL TREATMENT

• Fibrotomy

• Temporalis Myotomy / Flap Sx

• Laser treatment (KTP-532)