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IntroductionBackgroundIn 1952, Schwartz coined the term atrophica idiopathica mucosa oris to describe an oral fibrosing disease he discovered in 5 Indian women from Kenya.1 Joshi subsequently coined the termed oral submucous fibrosis (OSF) for the condition in 1953.2 Oral submucous fibrosis is a chronic debilitating disease of the oral cavity characterized by inflammation and progressive fibrosis of the submucosal tissues (lamina propria and deeper connective tissues). Oral submucous fibrosis results in marked rigidity and an eventual inability to open the mouth.3,4 The buccal mucosa is the most commonly involved site, but any part of the oral cavity can be involved, even the pharynx.5 The condition is well recognized for its malignant potential and is particularly associated with areca nut chewing, the main component of betel quid. Betel quid chewing is a habit practiced predominately in Southeast Asia and India that dates back for thousands of years. It is similar to tobacco chewing in westernized societies. The mixture of this quid, or chew, is a combination of the areca nut (fruit of the Areca catechu palm tree, erroneously termed betel nut) and betel leaf (from the Piper betel, a pepper shrub), tobacco, slaked lime (calcium hydroxide), and catechu (extract of the Acacia catechu tree).3 Lime acts to keep the active ingredient in its freebase or alkaline form, enabling it to enter the bloodstream via sublingual absorption. Arecoline, an alkaloid found in the areca nut, promotes salivation, stains saliva red, and is a stimulant.The ingredients and nomenclature of betel quid vary by region as detailed below6,7 : Pan: This is freshly prepared betel quid (with or without tobacco). Gutka (gutkha, guttkha, or guthka): This is a manufactured version of betel quid with tobacco sold as a single-use sachet. It is primarily used on the Indian subcontinent (ie, India, Pakistan, Bangladesh). Betel quid without tobacco is mostly used in Southeast Asian countries (ie, Taiwan, Myanmar, Thailand, China, Papua New Guinea, Guam). Pan masala: This is a commercially manufactured powdered version of betel quid without tobacco used in the Indian subcontinent. Pan Parag: It is a brand name of pan masala and gutka used in India. Mawa (kharra): This is a crude combination of areca, tobacco, and lime. Mainpuri tobacco: Popular in parts of northern India, Mainpuri tobacco is a mixture of areca nut, tobacco, lime, and various condiments. Depending on local preferences, sweeteners or spices (ie, cardamom, saffron, clove, anise seed, turmeric, mustard) are also added as flavorings.In most patients with oral submucous fibrosis, areca nut was chewed alone more frequently than it was chewed in combination with pan (ie, betel leaf plus lime plus betel catechu, with or without tobacco)4 or had a higher areca nut content.8 PathophysiologyThe pathogenesis of the disease is not well established, but the cause of oral submucous fibrosis is believed to be multifactorial. A number of factors trigger the disease process by causing a juxtaepithelial inflammatory reaction in the oral mucosa. Factors include areca nut chewing, ingestion of chilies, genetic and immunologic processes, nutritional deficiencies, and other factors. Areca nut (betel nut) chewingThe areca nut component of betel quid plays a major role in the pathogenesis of oral submucous fibrosis.9 In a 2004 study, a clear dose-dependent relationship was observed for both frequency and duration of chewing areca nut (without tobacco) in the development of oral submucous fibrosis.10 Smoking and alcohol consumption alone, habits common to areca nut chewers, have been found to have no effect in the development of oral submucous fibrosis,11 but their addition to areca nut chewing can be a risk for oral submucous fibrosis.11 Commercially freeze-dried products such as pan masala, guthka, and mawa have higher concentrations of areca nut per chew and appear to cause oral submucous fibrosis more rapidly than self-prepared conventional betel quid, which contains smaller amounts of areca nut.8 Arecoline, an active alkaloid found in betel nuts, stimulates fibroblasts to increase production of collagen by 150%.12 In one study, arecoline was found to elevate the mRNA and protein expression of cystatin C, a nonglycosylated basic protein consistently up-regulated in a variety of fibrotic diseases, in a dose-dependent manner in persons with oral submucous fibrosis.13 In 3 separate but similar studies, keratinocyte growth factor-1, insulinlike growth factor-1, and interleukin 6 expression, which have all been implicated in tissue fibrogenesis, were also significantly up-regulated in persons with oral submucous fibrosis due to areca quid chewing, and arecoline may be responsible for their enhanced expression.14,15,16 Further studies have shown that arecoline is an inhibitor of metalloproteinases (particularly metalloproteinase-2) and a stimulator of tissue inhibitor of metalloproteinases, thus decreasing the overall breakdown of tissue collagen.17 Insertion/deletion 5A polymorphism in the promoter region of the matrix metalloproteinase-3 gene, which results in alteration of transcriptional activities, has also been found in persons with oral submucous fibrosis but not in those withoral squamous cell carcinoma.18 Conversely, insertion/deletion 2G polymorphism in the promoter of the matrix metalloproteinase-1 gene has been implicated in oral squamous cell carcinoma but not oral submucous fibrosis.19 Flavanoid, catechin, and tannin in betel nuts cause collagen fibers to cross-link, making them less susceptible to collagenase degradation.20 This results in increased fibrosis by causing both increased collagen production and decreased collagen breakdown.4 Oral submucous fibrosis remains active even after cessation of the chewing habit, suggesting that components of the areca nut initiate oral submucous fibrosis and then affect gene expression in the fibroblasts, which then produce greater amounts of normal collagen.21 Chewing areca quid may also activate NF-kappaB expression, thereby stimulating collagen fibroblasts and leading to further fibrosis in persons with oral submucous fibrosis.22 Areca nuts have also been shown to have a high copper content, and chewing areca nuts for 5-30 minutes significantly increases soluble copper levels in oral fluids. This increased level of soluble copper supports the hypothesis that copper acts as an initiating factor in persons with oral submucous fibrosis by stimulating fibrogenesis through up-regulation of copper-dependent lysyl oxidase activity.23 Further, a significant gradual increase in serum copper levels from precancer to cancer patients has been documented,24 which may have a role in oral fibrosis to cancer pathogenesis.Ingestion of chiliesThe role of chili ingestion in the pathogenesis of oral submucous fibrosis is controversial. The incidence of oral submucous fibrosis is lower in Mexico and South America than in India, despite the higher dietary intake of chilies.25 A hypersensitivity reaction to chilies is believed to contribute to oral submucous fibrosis.4 One study demonstrated that the capsaicin in chilies stimulates widespread palatal fibrosis in rats,26 while another study failed to duplicate these results.27 Genetic and immunologic processesA genetic component is assumed to be involved in oral submucous fibrosis because of the existence of reported cases in people without a history of betel nut chewing9,28 or chili ingestion.28 Patients with oral submucous fibrosis have been found to have an increased frequency of HLA-A10, HLA-B7, and HLA-DR3.4 An immunologic process is believed to play a role in the pathogenesis of oral submucous fibrosis.29 The increase in CD4 and cells with HLA-DR in oral submucous fibrosis tissues suggests that most lymphocytes are activated and that the number of Langerhans cells is increased. The presence of these immunocompetent cells and the high ratio of CD4 to CD8 in oral submucous fibrosis tissues suggest an ongoing cellular immune response that results in an imbalance of immunoregulation and an alteration in local tissue architecture.30 These reactions may be the result either of direct stimulation from exogenous antigens, such as areca alkaloids, or of changes in tissue antigenicity that lead to an autoimmune response.30 Further, the major histocompatibility complex class I chainrelated gene A (MICA) is expressed by keratinocytes and other epithelial cells and interacts with gamma/delta T cells localized in the submucosa. MICA has a triplet repeat (GCT) polymorphism in the transmembrane domain, resulting in 5 distinct allelic patterns. In particular, the phenotype frequency of allele A6 of MICA in subjects with oral submucous fibrosis is significantly higher and suggests a risk for oral submucous fibrosis.31 Some authors have demonstrated increased levels of proinflammatory cytokines and reduced antifibrotic interferon gamma (IFN-gamma) in patients with oral submucous fibrosis, which may be central to the pathogenesis of oral submucous fibrosis.32 Nutritional deficienciesIron deficiency anemia, vitamin B complex deficiency, and malnutrition are promoting factors that derange the repair of the inflamed oral mucosa, leading to defective healing and resultant scarring.4 The resulting atrophic oral mucosa is more susceptible to the effects of chilies and betel nuts.Other significant factorsSome authors have found a high frequency of mutations in the APC gene and low expression of the wild-type TP53 tumor suppressor gene product in patients with oral submucous fibrosis, providing some explanation for the increased risk of oral squamous cell carcinoma development in patients with oral submucous fibrosis.9 Other studies have suggested that altered expression of retinoic acid receptor-beta may be related to the disease pathogenesis.33 FrequencyUnited StatesOral submucous fibrosis is rare in the United States and is found only in the immigrant members of the South Asian population who chew betel nuts.InternationalWorldwide, estimates of oral submucous fibrosis indicate that 2.5 million people are affected, with most cases concentrated on the Indian subcontinent, especially southern India.3 The rate varies from 0.2-2.3% in males and 1.2-4.57% in females in Indian communities.4 Oral submucous fibrosis is widely prevalent in all age groups and across all socioeconomic strata in India. A sharp increase in the incidence of oral submucous fibrosis was noted after pan parag came onto the market, and the incidence continues to increase. Oral submucous fibrosis also occurs in other parts of Asia and the Pacific Islands.3 Migration of endemic betel quid chewers has also made oral submucous fibrosis a public health issue in many parts of the world, including the United Kingdom, South Africa, and many Southeast Asian countries.34 Mortality/MorbidityOral submucous fibrosis has a high rate of morbidity because is causes a progressive inability to open the mouth, resulting in difficulty eating and consequent nutritional deficiencies. Oral submucous fibrosis also has a significant mortality rate because of it can transform into oral cancer, particularly squamous cell carcinoma, at a rate of 7.6%.4 RaceOral submucous fibrosis occurs on the Indian subcontinent, in Indian immigrants to other countries, and among Asians and Pacific Islanders as a result of the traditional use of betel quid endemic to these areas.3 SexThe male-to-female ratio of oral submucous fibrosis varies by region, but females tend to predominate. In a study from Durban, South Africa, a distinct female predominance was demonstrated, with a male-to-female ratio of 1:13.35 This was later confirmed by others, with a male-to-female ratio of 1:7.36 In addition, a female predominance in areca nut chewing was also noted in this region. Studies in Pakistan reported a male-to-female ratio of 1:2.3.4

Conversely, a case-control study of 185 subjects in Chennai, South India revealed a male-to-female ratio 9.9:1.11 In Patna, Bihar (also in India), the male-to-female ratio was 2.7:1.37 With the onset of new commercial betel quid preparations, trends in sex predominance and age of occurrence may shift.AgeThe age range of patients with oral submucous fibrosis is wide and regional; it is even prevalent among teenagers in India. In a study performed in Saipan, 8.8% of teenagers with a mean age of 16.3 years ( 1.5 y) were found to have oral submucous fibrosis.38 Generally, patient age ranges from 11-60 years4,37 ; most patients are aged 45-54 years and chew betel nuts 5 times per day.4 ClinicalHistorySymptoms of oral submucous fibrosis include the following3 : Progressive inability to open the mouth (trismus) due to oral fibrosis and scarring Oral pain and a burning sensation upon consumption of spicy foodstuffs Increased salivation Change of gustatory sensation Hearing loss due to stenosis of the eustachian tubes Dryness of the mouth Nasal tonality to the voice Dysphagia to solids (if the esophagus is involved) Impaired mouth movements (eg, eating, whistling, blowing, sucking)PhysicalOral submucous fibrosis is clinically divided into 3 stages,39 and the physical findings vary accordingly, as follows3,4,39 : Stage 1: Stomatitis includes erythematous mucosa, vesicles, mucosal ulcers, melanotic mucosal pigmentation, and mucosal petechia. Stage 2: Fibrosis occurs in ruptured vesicles and ulcers when they heal, which is the hallmark of this stage. Early lesions demonstrate blanching of the oral mucosa. Older lesions include vertical and circular palpable fibrous bands in the buccal mucosa and around the mouth opening or lips, resulting in a mottled, marblelike appearance of the mucosa because of the vertical, thick, fibrous bands running in a blanching mucosa. Specific findings include the following: Reduction of the mouth opening (trismus) Stiff and small tongue Blanched and leathery floor of the mouth Fibrotic and depigmented gingiva Rubbery soft palate with decreased mobility Blanched and atrophic tonsils Shrunken budlike uvula Sinking of the cheeks, not commensurate with age or nutritional status Stage 3: Sequelae of oral submucous fibrosis are as follows: Leukoplakia is precancerous and is found in more than 25% of individuals with oral submucous fibrosis. Speech and hearing deficits may occur because of involvement of the tongue and the eustachian tubes.CausesThe term oral submucosal fibrosis derives from oral (meaning mouth), submucosal (meaning below the mucosa of the mouth), and fibrosis (meaning hardening and scarring).4 Chewable agents, primarily betel nuts (Areca catechu), contain substances that irritate the oral mucosa, making it lose its elasticity. Nutritional deficiencies, ingestion of chilies, and immunologic processes may also have a role in the development of oral submucous fibrosis.3 See Pathophysiology.Differential DiagnosesOther Problems to Be ConsideredAmyloidosis: Hyalinized stroma can be distinguished from amyloid infiltration by using Congo red and thioflavine T staining under polarized and immunofluorescent light, respectively. Generalized fibromatosis: Although soft tissue masses are not produced in the usual sense, the fibrosis of oral submucous fibrosis may be confused with generalized fibromatosis.Oral manifestations of scleroderma: Scleroderma can be distinguished by other cutaneous, systemic, and characteristic laboratory findings. A case of localized plaque-type morphea was seen in a patient with long-standing oral submucous fibrosis.40 Oral lichen planus: Wickham striae can mimic atrophy and fibrosis.Anemia: Pale oral mucosa can mimic atrophy and fibrosis.WorkupLaboratory Studies No specific laboratory tests are available for oral submucous fibrosis, and abnormalities may be related to secondary nutritional deficiencies. Some oral submucous fibrosis studies have reported the following laboratory findings: Decreased hemoglobin levels Decreased iron levels Decreased protein levels Increased erythrocyte sedimentation rate Decreased vitamin B complex levelsOther Tests Cytologic smears may be performed. A neural networkbased oral precancer stage detection method has been proposed.34 This new technique uses wavelet coefficients from transmission electron micrography images of subepithelial fibrillar collagen in healthy oral submucosa and in oral submucous fibrosis tissues. These wavelet coefficients are used to choose the feature vector, which, in turn, can be used to train an artificial neural network. This trained network is able to classify normal and oral precancer stages (less advanced and advanced) after obtaining the image as an input. This technology is not readily available but could theoretically be used as an adjunct to hematoxylin and eosin histologic evaluations.Procedures Currently, oral biopsy for hematoxylin and eosin provides the most definitive diagnosis and is crucial because of the association of oral submucous fibrosis with oral cancer.4 Some authorities have reported benefit with immunohistochemical techniques such as Masson trichrome staining when pathology involved muscle.41 Alteration of cytokeratin expression, as is seen in leukoplakia and oral cancer, has also been noted in oral submucous fibrosis. Increased intensity of staining for pancytokeratin and high molecular weight cytokeratin, aberrant expression of cytokeratin 8, and decreased expression of cytokeratins 5 and 14 suggest their potential as surrogate markers for malignant transformation.42 Histologic FindingsHistologic findings vary according to the stage of the disease. Very early stageFine fibrillar collagen, marked edema, large fibroblasts, dilated and congested blood vessels, and inflammatory infiltrates (primarily polymorphonuclear leukocytes and eosinophils) are found.Early stageEarly hyalinization is characterized by thickened collagen bundles, moderate numbers of fibroblasts, and inflammatory cells (primarily lymphocytes, eosinophils, and plasma cells).Moderately advanced and advanced stagesDense bundles and sheets of collagen, thick bands of subepithelial hyalinization extending into the submucosal tissues (replacing fat or fibrovascular tissue), decreased vascularity, no edema, and inflammatory cells (lymphocytes and plasma cells) are found.Oral submucous fibrosis is generally characterized by diffuse hyalinization of the subepithelial stroma with pigment incontinence from the overlying epithelial melanin.43 Other histologic findings include an atrophic epithelium and intercellular edema, with or without hyperkeratosis, parakeratosis, or orthokeratosis; epithelial dysplasia (25% of patients who underwent biopsy); squamous cell carcinoma histologically identical to typical squamous cell carcinomas; chronic inflammation and fibrosis in the minor salivary glands in the area of quid placement; and atrophy of the underlying muscle.29 Ultrastructural changes in oral submucous fibrosis include an increase in collagen type I; however, fibrils retain the normal structure.44 StagingIn addition to the above clinical staging, in 1995 Khanna and Andrade40 developed a group classification system for the surgical management of trismus. Group I: This is the earliest stage and is not associated with mouth opening limitations. It refers to patients with an interincisal distance of greater than 35 mm. Group II: This refers to patients with an interincisal distance of 26-35 mm. Group III: These are moderately advanced cases. This stage refers to patients with an interincisal distance of 15-26 mm. Fibrotic bands are visible at the soft palate, and pterygomandibular raphe and anterior pillars of fauces are present. Group IVA: Trismus is severe, with an interincisal distance of less than 15 mm and extensive fibrosis of all the oral mucosa. Group IVB: Disease is most advanced, with premalignant and malignant changes throughout the mucosa.TreatmentMedical CareThe treatment of patients with oral submucous fibrosis depends on the degree of clinical involvement. If the disease is detected at a very early stage, cessation of the habit is sufficient. Most patients with oral submucous fibrosis present with moderate-to-severe disease. Moderate-to-severe oral submucous fibrosis is irreversible. Medical treatment is symptomatic and predominantly aimed at improving mouth movements. Treatment strategies include the following4 : Steroids: In patients with moderate oral submucous fibrosis, weekly submucosal intralesional injections or topical application of steroids may help prevent further damage. Placental extracts: The rationale for using placental extract in patients with oral submucous fibrosis derives from its proposed anti-inflammatory effect,45 hence, preventing or inhibiting mucosal damage. Cessation of areca nut chewing and submucosal administration of aqueous extract of healthy human placental extract (Placentrex) has shown marked improvement of the condition.46 Hyaluronidase: The use of topical hyaluronidase has been shown to improve symptoms more quickly than steroids alone. Hyaluronidase can also be added to intralesional steroid preparations. The combination of steroids and topical hyaluronidase shows better long-term results than either agent used alone.47 IFN-gamma: This plays a role in the treatment of patients with oral submucous fibrosis because of its immunoregulatory effect. IFN-gamma is a known antifibrotic cytokine. IFN-gamma, through its effect of altering collagen synthesis, appears to be a key factor to the treatment of patients with oral submucous fibrosis, and intralesional injections of the cytokine may have a significant therapeutic effect on oral submucous fibrosis.48 Lycopene: Newer studies highlight the benefit of this oral nutritional supplement at a daily dose of 16 mg. Mouth opening in 2 treatment arms (40 patients total) was statistically improved in patients with oral submucous fibrosis. This effect was slightly enhanced with the injection of intralesional betamethasone (two 1-mL ampules of 4 mg each) twice weekly, but the onset of effect was slightly delayed.49 Pentoxifylline: In a pilot study, 14 test subjects with advanced oral submucous fibrosis given pentoxifylline at 400 mg 3 times daily were compared to 15 age- and sex-matched diseased control subjects. Statistical improvement was noted in all measures of objective (mouth opening, tongue protrusion, and relief from fibrotic bands) and subjective (intolerance to spices, burning sensation of mouth, tinnitus, difficulty in swallowing, and difficulty in speech) symptoms over a 7-month period.50 Further studies are needed, but this could be used in conjunction with other therapies.The role of these treatments is still evolving. The US Food and Drug Administration has not yet approved these drugs for the treatment of oral submucous fibrosis.Surgical CareSurgical treatment is indicated in patients with severe trismus and/or biopsy results revealing dysplastic or neoplastic changes. Surgical modalities that have been used include the following: Simple excision of the fibrous bands: Excision can result in contracture of the tissue and exacerbation of the condition. Split-thickness skin grafting following bilateral temporalis myotomy or coronoidectomy: Trismus associated with oral submucous fibrosis may be due to changes in the temporalis tendon secondary to oral submucous fibrosis; therefore, skin grafts may relieve symptoms.29 Nasolabial flaps and lingual pedicle flaps: Surgery to create flaps is performed only in patients with oral submucous fibrosis in whom the tongue is not involved.51 Use of a KTP-532 laser release procedure was found to increase mouth opening range in 9 patients over a 12-month follow-up period in one study.52 Consultations Consult an ear, nose, and throat specialist for evaluation of dysplasia and close follow-up monitoring for the development of oral cancer. Consult a plastic surgeon for patients with severe trismus, in whom reconstructive surgery may be possible.Diet Dietary focus should be on reducing exposure to the risk factors, especially the use of betel quid, and correcting any nutritional deficiencies, such as iron and vitamin B complex deficiencies.3 Activity Physical therapy using muscle-stretching exercises for the mouth may be helpful in preventing further limitation of mouth movements. Thisis oftencombined with medical and surgical therapy.MedicationThe goals of pharmacotherapy are to reduce morbidity and to prevent complications. In addition to the medications listed below, placental extract has been used experimentally at a dose of 50 mcg/m2 SC 3 times per week if the patient's body surface area (BSA) is greater than 0.52 m2 or 1.5 mcg/kg/dose SC 3 times per week if the BSA is less than or equal to 0.5 m2.CorticosteroidsCan be used in pharmacologic doses for their anti-inflammatory and immunosuppressant properties and their effects on blood and lymphatic systems in the palliative treatment of various diseases.

Dexamethasone (Decadron)For various inflammatory diseases. Decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reducing capillary permeability. Dosing Interactions Contraindications PrecautionsAdult4 mg IV/IM (suggested in studies)PediatricBase dose on severity of disease and response rather than age, body weight, or BSA Dosing Interactions Contraindications PrecautionsEffects decrease with coadministration of barbiturates, phenytoin, and rifampin; decreases effect of salicylates and vaccines used for immunization Dosing Interactions Contraindications PrecautionsDocumented hypersensitivity; active bacterial or fungal infection Dosing Interactions Contraindications PrecautionsPregnancyC - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetusPrecautionsIncreases risk of multiple complications, including severe infections; monitor adrenal insufficiency when tapering drug; abrupt discontinuation of glucocorticoids may cause adrenal crisis; hyperglycemia, edema, osteonecrosis, myopathy, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, myasthenia gravis, growth suppression, and infections are possible complications; caution with individuals exposed to viral illnesses, such as chickenpox or measles

Triamcinolone acetonide (Aristocort, Kenaject)Suppresses immune system by reducing activity and volume of lymphatic system. Treats inflammatory mucosal lesions that are responsive to steroids. Decreases inflammation by suppressing the migration of polymorphonuclear leukocytes and by reversing capillary permeability. Dosing Interactions Contraindications PrecautionsAdultDental paste (for oral inflammatory or ulcerative lesions): Apply thin film bid/tid pc and hsIM: 40-80 mg (studies have used 10 mg/mL diluted in 1 mL of lidocaine 2% to avoid tissue irritation and facilitate proper distribution of drug)PediatricNot established Dosing Interactions Contraindications PrecautionsCoadministration with barbiturates, phenytoin, and rifampin decreases effects; effects of vaccine and toxoid may be reduced Dosing Interactions Contraindications PrecautionsDocumented hypersensitivity; fungal, viral, and mycobacterial mucosal infections Dosing Interactions Contraindications PrecautionsPregnancyC - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetusPrecautionsMultiple complications (eg, severe infections, hyperglycemia, edema, osteonecrosis, myopathy, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, myasthenia gravis, growth suppression) may occur; abrupt discontinuation may cause adrenal crisis

Betamethasone valerate (Diprosone)For inflammatory reactions responsive to steroids. Decreases inflammation by suppressing migration of polymorphonuclear leukocytes and by reversing capillary permeability. Affects production of lymphokines and has inhibitory effect on Langerhans cells. Dosing Interactions Contraindications PrecautionsAdultSuggested dose: 0.05% topically q6h for 3 wkPediatricNot established Dosing Interactions Contraindications PrecautionsNone reported Dosing Interactions Contraindications PrecautionsDocumented hypersensitivity; paronychia; cellulitis; impetigo; angular cheilitis; erythrasma; erysipelas; rosacea; perioral dermatitis; acne Dosing Interactions Contraindications PrecautionsPregnancyC - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetusPrecautionsDo not use on skin with decreased circulation; can cause atrophy of groin, face, and axillae; may cause striae distensae and rosacealike eruption; may increase skin fragility; rarely may suppress HPA axis; if infection develops and is not responsive to antibiotic treatment, discontinue until infection is under control; do not use monotherapy to treat widespread plaque psoriasisExtravasation antidotesCan enhance diffusion of locally irritating or toxic drugs in the management of intravenous extravasation.

Hyaluronidase (Wydase Injection)Stimulates hydrolysis of hyaluronic acid, one of the chief ingredients of tissue cement, which offers resistance to diffusion of liquids through tissues. Used to aid in absorption and dispersion of injected drugs. Dosing Interactions Contraindications PrecautionsAdult150 U added to vehicle solution and administered SC/IDPediatricAdminister as in adults Dosing Interactions Contraindications PrecautionsSalicylates, cortisone, corticotropin, estrogens, and antihistamines may decrease effects Dosing Interactions Contraindications PrecautionsDocumented hypersensitivity Dosing Interactions Contraindications PrecautionsPregnancyC - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetusPrecautionsAvoid injecting into inflamed or cancerous areas; perform intradermal skin test for sensitivity before initiating infusion; discontinue if sensitivity or extravasation occurInterferonsNaturally produced proteins with antiviral, antitumor, and immunomodulatory actions. Alpha-, beta-, and gamma-interferons may be given topically, systemically, or intralesionally.

Interferon gamma (Actimmune)Believed to act via ability to counteract cell surface expression of proinflammatory or proadhesion molecules on immune cells, among other effects. More studies needed to fully understand mechanisms of action. Dosing Interactions Contraindications PrecautionsAdultBSA >0.5 m2: 50 mcg/m2 SC 3 times/wkBSA 2) and 129 genes were down-regulated (fold value 0.96, the tissues are post treated OSF mucosa. Thus, it is interestingly observed that the ratio values of the post treated OSF group have enhanced to greater than 0.96, as in the case of normal subjects, indicating the response of treatment and the transformation of the OSF toward normalcy.

Comparison of treatment response between autofluorescence and conventional clinical methods

In order to verify whether the autofluorescence technique is comparable with that of conventional clinical methods to monitor the treatment response, the pre- and post OSF patients were subjected to measurement of maximal mouth opening, tongue protrusion and the severity of burning sensation [Figure 8]. The mean SD of these three parameters was also estimated [Table 4].

The mean ( SD) maximal mouth opening of the post treated OSF group was significantly higher than that of the pre treated OSF group (P < 0.001 ** ). The mean ( SD) tongue protrusion of the post treated OSF patients was significantly higher than that of the pre treated oral submucous fibrosis patients (P < 0.001 ** ) [Figure 6]. The mean ( SD) severity of burning sensation of the post treated OSF patients was significantly lower than that of the pre treated OSF patients (P < 0.001 ** ). All the three clinical parameters showed high statistical significance, with P < 0.001, as in the case of classification of the pre treated oral submucous fibrosis mucosa from the post treated OSF mucosa, using the autofluorescence technique. Further, from the scattered plot, it is verified that the ratio value 0.96 is greater for both the normal oral mucosa and the post treated OSF mucosa. Of the 20 treated patients, only one patient's R-value was < 0.96, indicating that autofluorescence may also be effectively used to monitor the therapeutic response.

Discussion

In this study, we found that with ultraviolet light at 330 nm excitation, the spectra of the OSF mucosa had an intense fluorescence emission at 385 nm and a secondary emission peak at 440 nm with that of the normal oral mucosa. In addition, the pre treated OSF mucosa had a significantly higher mean value of I 385 5 nm , a significantly lower mean value of I 440 5 nm and a significantly lower mean ratio of I 440 5 nm /I 385 5 nm than the normal oral mucosa (P < 0.001). Previous studies have shown that at 330 nm excitation, the 380 and 460 nm emission peaks of the autofluorescence spectra for oral mucosal tissues reflect the collagen content in the subepithelial connective tissue and the NADH content in the epithelial cells, respectively. [7],[10],[12] Therefore, the increased subepithelial collagen content could explain why the pre treated OSF mucosa had a significantly higher intensity of the 385 nm emission peak of the autofluorescence spectra than the normal oral mucosa and the post treated OSF mucosa. Furthermore, compared with the normal oral epithelium, the markedly atrophic OSF epithelium allowed more excitation energy to penetrate into the subepithelial connective tissue and more collagen- derived emission fluorescence to go through. This factor also contributed to the high intensity of the 385 nm emission peak of the autofluorescence spectra of the OSF mucosa. In addition, the markedly atrophic OSF epithelium might contain less amount of NADH than the normal oral epithelium. The fibrosis-induced reduction of blood vessels in the lamina propria might also diminish the metabolic rate of the oral epithelial cells, which, in turn, results in a lower NADH content in the OSF epithelium. Therefore, the OSF mucosa had a significantly lower intensity of the 440 nm emission peak than the normal oral mucosal sites. This suggests that autofluorescence spectroscopy can detect the increased amount of collagen in the subepithelial connective tissue and the decreased amount of NADH in the epithelium. The monochromatic light signal penetrates only about 500 m deep into the tissue. Thus, this technique is capable of analyzing only the most superficial portions of the oral lesions. [9] In this study, no significant differences in the pattern of the 385 and 440 nm emission band was found between the normal oral mucosa and the post treated OSF mucosa.

Steroids are well known to act as antiinflammatory agents for prevention or suppression of the fibroproductive inflammation found in the OSF mucosa thus ameliorating this fibrocollagenous condition. [5] Tsai et al. had suggested that in addition to the known mechanisms, a corticosteroid-induced increase in collagen degradation could result from enhanced collagen phagocytosis by the fibroblast. [11] Hyaluarnidase degrades the hyaluaronic acid matrix actively, promoting lysis of the fibrinous coagulum. [4] It is due to the above actions that the collagen content of the OSF mucosa had reduced and the atrophic oral epithelium had healed. Hence, following the treatment, there is a similar fluorescence characteristic as in the case of the normal oral mucosa. The improvement in mouth opening, tongue protrusion and decrease in the burning sensation when compared with the initial stage was highly significant and correlated well with the autofluorescence characteristics. This again is attributed to treatment efficacy, resulting in collagen degradation and decrease in the inflammation.

Conclusion

In summary, the change in the fluorescence emission spectrum for both the normal and the OSF mucosa before and after treatment can be explained by analyzing the changes in the fluorescence intensity of endogenous fluorophores. This study adds evidence that high collagen and low NADH characterize the OSF mucosa. It is also obvious from this study that autofluorescence spectroscopy can monitor the therapeutic response and characterize the tissue transformation following treatment. Furthermore, investigations with a large group of experimental subjects will also be useful for the development of a statistical database and a user-friendly diagnostic algorithm that could facilitate early detection. Autofluorescence spectroscopy being a non invasive and easily applicable tool for the detection of the alterations in the structural and biochemical composition of cells may reduce the patient morbidity and, therefore, is of great clinical importance. From this study, we conclude that autofluorescence spectroscopy provides valuable information for the diagnosis and also for monitoring the therapeutic response in OSF. However, results of this study on autofluorescence characteristics in the diagnosis and therapeutic monitoring in OSF has to be validated with more studies involving large samples and longer follow-up.

Acknowledgments

We express our sincere thanks to our Principal, the faculties in the Departments of Oral Medicine and Radiology, Tamilnadu Government Dental College and Hospital, and Mr. Sivabalan, Research Scholar, Department of Medical Physics, Anna University, for their valuable suggestions, kind help and encouragement in the present study.

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