Oral Submucous Fibrosis: a chronic debilitating disease of the oral cavity characterized by inflammation and progressive fibrosis of the sub mucosal tissues.

Clinical Features:

Early OSF-Prodromal symptoms:

Burning sensation in the mouth on consuming spicy food,

Blisters on the palate

Ulcerations or recurrent generalized inflammation of the oral mucosa,

excessive salivation,

defective gustatory sensation,

dryness of the mouth

Periods of exacerbations with appearance of small vesicles in the cheek and palate.

Petichiae are observed on tongue followed by labial and buccal mucosa.

Pain in area with submucosal fibrotic bands on palpation is a useful clinical test.

Histologically-

Hyperplastic epithelium

Numerous dilated and blood filled capillaries juxtaepithelially.

Inflammatory cells: lymphocytes, plasma cells.

Large number of Lymphocytes, fibroblasts and plasma cells suggest  tissue reaction leading to  OSF

Advanced OSF:

Oral mucosa  becomes blanched and slightly opaque and white fibrous bands appear

Buccal mucosa, lips, palate and faucial pillars are affected

Oral mucosa is involved symmetrically and fibrous bands in the buccal mucosa run in vertical direction

Soft Palate:

initially: fibrous depostis varies from slight whitish areas on soft palate, with no symptoms

later: dense fibrosis, causing fixation and shortening or even deviation of uvula and soft palate.

Faucial Pillars: ranges from slight sub mucosal accumulation in both pillars to a dense fibrosis extending deep into the pillars with strangulation of tonsils.

Difficulty in mouth opening is due to Dense Fibrosis involving the tissues around the pterygomandibular raphae.

In severe cases the Fibrosis may spread to Pharynx and down the piriform fossae

Circular bands are felt around the entire Rima Oris(mouth orifice) and seen more around the lower lip.

Tongue: Decreased movement and atrophy of tongue papillae.

With Progressive fibrosis the following changes can be seen :

• Difficulty in mouth opening
• Inability to whistle
• Difficulty to blow out a candle
• Difficulty in swallowing

Fibrosis involving Nasopharynx:  Referred pain to the ear, nasal voice

Epidimiology:

Sex- F>M

Etiology:

• Habitual areca Nut chewing is the main cause which leads to
• Stimulation of Fibroblast proliferation leading to excessive collagen synthesis.
• Decreased secretion of collagenase

Pathology:

Structural and Microstructural changes:

Epithelial changes in different  stages of OSF

Early stage – Hyperplasia

Advanced stage – Atrophy

Lesions of Palate – Orthokeratosis

Lesions of the buccal mucosa – Parakeratosis

Sub Epithelial changes:

On the basis of histopathological appearances OSF can be divided into 4 stages:

• Very early
• Early
• Moderately advanced
• Advanced

Criteria for classification:

• Subepithelial collagen
• Presence or absence of edema
• Physical state of mucosal collagen
• State of blood vessels

Predominant inflammatory cell types are mainly lymphocytes and plasma cells

Management:

The reduction or even elimination of the habit of arecanut chewing is an important preventive measure.

Nutritional Support

Immunomodulatory drugs

Physiotherapy – Which includes regular excercise by patient at home, which comprises of Forceful opening of mouth against pressure and regular opening and closing of mouth.

Local Drug delivery – Local injections of Corticosteroids and Placental Extracts

Combined Therapy – All the above techniques are used together

Surgical Management- Forcing the mouth open and cutting the fibrotic bands

It is also described as “Dilaceration is the result of a developmental anomaly in which there has been an abrupt change in the axial inclination between the crown and the root of a tooth”

It occurs as a result of trauma to the predecessors of the permanent teeth, and it is seen that Dilaceration of the root is more common than that of crown.

Etiology: The cause of this anamolie in the shape of the tooth has two main reasons:

• Trauma
• Developmental disturbances
• Developmental Syndromes

Dilaceration is seen in both Permanent and Deciduos teeth equally.

Pain is not necessarily associated with ongoing tissue damage, it is a subjective experience and has an emotional as well as a sensory component.

As a doctor we can say that Pain is our friend, as it is the main reason for a patient to come to a doctor, according to stats out of all the patients who come to a doctor 90% of the patients visit a doctor due to pain.

Pain is very difficult to describe inspite of many efforts to establish ways to classify and describe it in a brief manner.

Pain is multi factorial and to control pain we have to eliminate the cause of pain, for instant relief we can use drugs but as pain is the surface symptom of an underlying disease we have to eliminate the cause of pain to relieve the patient permanently.

Classification:

Pain cannot be classified under a particular aetiology and pathogenesis as aetiology and pathogenesis of pain is multifactorial. So pain is classified according to

• Aetiology and pathogenesis.
• Duration.
• Site.

Aetiology and pathogenesis:

1. Here the pain is classified according to the cause and the pathogenesis of the disease:
2. Physiological: An acute response to an injury.
3. Inflammatory: When pain is generated and maintained mainly by inflamatory mediators.
4. Cancer related pain: Aetiology is usually multifactorial. It may be predominantly physiological, inflammatory, neuropathic or ischaemic, or combination of the above.
5. Neuropathic: Pain arising from injury or dysfunction of the central or peripheral nervous system.
6. Central: Pain caused by a lesion or or dysfunction of the central nervous system. It can affect brain or spinal cord, or both.
7. Ischemic: It is mainly due to the decrease in blood supply to the organs, or the nerves that supply them.
8. Psyhogenic: Pain especially chronic pain has both an emotional and a behavioural component, But a purely psychogenic pain is rare.

Duration:

It is mainly divided into 2 types:

1. Acute: It is mainly cause by response to an injury, it disappears with the withdrawal of the noxious stimulus, or when the injury is healed.
2. Chronic: This is a more complicated version of pain as it is associated with a serious pathological condition, Pain is considered to be chronic when the pain persists for more than 3 months, the main reasons for chronic pain are malignancies or rheumatoid arthritis or any pathological condition which persists for longer duration. Chronic pain is associated with disability and a significant behavioural response.

Site:

1. Somatic: It is usually localized pain, which is confined to a particular area.
2. Visceral: Poorly localized, it is spread over a large area which cannot be precisely located.
3. Referred: Pain which is felt at one site but the cause or aetiology of the pain is at some other site. For ex: during cardiac problem the pain is felt in the left arm in the upper part of abdomen etc.

If you have less saliva in your mouth, your teeth and gums are at increased risk of tooth decay.  People with xerostomia also are more likely to get illnesses that affect the soft tissues of the mouth, such as yeast infections (thrush). In addition, your diet may be affected because you cannot taste food as you normally would.

Xerstomia- dry mouth

Causes of Xerostomia include:

• A side effect of medicine — Hundreds of drugs can cause dry mouth. These include pain relievers and medicines for depression, cold symptoms and allergies. Medicines are the most common cause of xerostomia. Older people often take many medicines, including those most likely to cause dry mouth. For this reason, they have an especially high rate of dry mouth. Some of the drugs which cause dry mouth are Tricyclic antidepressants, antihistamines, anti hypertensives, anti depressants, bronchodialtors and Diuretics.
• A complication of diseases and infections — Several diseases are associated with dry mouth. They include diabetes, anemia, cystic fibrosis, rheumatoid arthritis, high blood pressure, Polyurea and HIV infection. Xerostomia also occurs with Sjogren’s syndrome. In this disease, the body’s antibodies attack the salivary and tear glands. Some viral infections, such as mumps, also affect saliva production and cause xerostomia.
• Dehydration — Any condition that leads to loss of body fluids can also cause xerostomia. These conditions include fever, excessive sweating, vomiting, diarrhea, blood loss or loss of water through the skin after a burn.
• Radiation therapy — Xerostomia is a common side effect of radiation therapy to treat cancers in the head, neck, adn thyroid cancers.
• Sjogrens syndrome.
• Poorly controlled Diabetes
• Bone marrow transplantation
• Thyroid Diorders
• Surgical removal of the salivary glands — If a mass develops in a salivary gland, surgical removal of the gland may be recommended.
• Psychological cases like anxiety and depression
• Duct Calculi
• Sialadenitis or inflamation of salivary glands
• Smoking controlling drug – Zuban
• Ectodermal Dysplasia
• Salivary gland Aplasia

Symptoms:

Although xerostomia is a symptom, it often occurs along with other symptoms. These may include:

• Frequent thirst
• Burning or tingling sensation, especially on the tongue
• Red, raw tongue
• Sores in mouth or at corners of lips
• Difficulty swallowing
• Problems with taste
• Sore throat and hoarseness
• Bad Breath
• Problems with speech
• Difficulty in swallowing
• Dry nasal passages
• Dry, cracked lips
• Increase in dental problems, such as caries.
• Difficulty wearing dentures
• Repeated yeast infections in the mouth
• Risk of caries
• Risk of Periodontal diseases

Diagnosis for Xerostomia:

Xerostomia is a symptom, not a disease. Tell your dentist and hygienist about your dry mouth. Your dentist will ask you about your medical history and your symptoms. And the dentist will ask about any drugs you are taking. This includes prescription. The dentist also will examine your mouth. He or she will assess the flow of saliva and look for cracks, sores, and signs of cavities and gum disease.

Prevention:

As i always say that,

“Prevention is better than cure”

To prevent dry mouth, avoid things that cause it, if possible. For example, if dry mouth is related to a medicine, your physician may be able to prescribe a drug that causes less dryness. You also can take steps to prevent or manage the symptoms of dry mouth.

Treatment for Xerostomia:

The treatment of xerostomia focuses on three areas:

• Relieving symptoms
• Preventing tooth decay
• Increasing the flow of saliva, if possible

Your doctor will recommend that you practice good dental hygiene. This means that you should brush and floss properly. You also should have regular dental visits. In the office, your dentist or hygienist also will regularly apply flouride to your teeth. Your physician may work with your dentist to manage your condition.

Treatment is based on how severe your problem is and what caused it. Fluoride treatments can be prescribed to help prevent cavities. Artificial saliva is available over the counter as a rinse, spray or gel. Depending on your medical condition and diagnosis, a doctor may prescribe a drug that causes more saliva to be released.

Here are some simple tips which might help you, try the following:

• Drink water often to keep your mouth moist. Carry water with you. Sip it throughout the day. Keep water by your bed at night.
• Suck on sugar-free hard candies, ice chips or sugar-free ice pops. Some doctors believe sugary candies are as likely as dry mouth to cause cavities.
• If you chew gum, try sugarless gum.
• Use an over-the-counter oral moisturizer or saliva substitute.
• Use mouth rinses or mouthwashes that do not contain alcohol.
• Avoid salty foods, dry foods (crackers, cookies, toast) and foods and beverages with high sugar contents.
• Avoid drinks containing alcohol or caffeine. These increase water loss by triggering frequent urination.
• Avoid smoking.
• To minimize irritation of dry tissues, use a moisturizer on your lips and a soft-bristle toothbrush on your teeth and gums.

Materials used for taking Impression:

The most commonly used material is

Zinc oxide Eugenol- It is the ideal material for impression taking.

It is used as it had good flow and can take the impression accurately and is mostly non reactive to most individuals and  is palatable to most individuals, and it does not compress the tissues and also does not generate heat.

The other materials used are

• Baseplate wax.
• Impression compound.
• Plaster of paris.

“Making an accurate and detailed impression is the first and most important step in creating superior prosthetic restorations.”