Oral submucous fibrosis (OSMF) is a chronic disease of oral mucosa characterized by inflammation and progressive fibrosis  followed by stiffening of an other wise yielding mucosa resulting in difficulty in opening the mouth. It is generally accepted today that areca nut quid plays a major role in the etiology .The younger generation is very much addicted to these products especially gutkha and panmasala. The condition is well recognized for its malignant potential. 

The pathogenesis of the disease is not well established, but the cause of OSMF is believed to be multifactorial. Factors include areca nut chewing, ingestion of chilies, genetic and immunologic processes, nutritional deficiencies, and other factors.Iron 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 .

The rate varies from 0.2-2.3% in males and 1.2-4.57% in females in Indian communities. OSMF is widely prevalent in all age groups and across all socioeconomic strata in India. ; it is even prevalent among teenagers in India, 8.8% of teenagers with a mean age 16.3 years (? 1.5 y) were found to have OSMF . Generally, patient age ranges from 11-60 years  most patients are aged 45-54 years and chew betel nuts 5 times per day .

Mortality/Morbidity: OSMF has a high rate of morbidity because is causes a progressive inability to open the mouth, resulting in  in eating and consequent nutritional deficiencies. OSMF also has a significant mortality rate becausef it can transform into oral cancer, particularly squamous cell carcinoma, at a rate of 7.6% .

History: Symptoms of OSMF include the following :

1. Progressive inability to open the mouth (trismus) due to oral fibrosis and scarring
2. Oral pain and a burning sensation upon consumption of spicy foodstuffs
3. Increased salivation
4. Change of gustatory sensation
5. Hearing loss due to stenosis of the eustachian tubes
6. Dryness of the mouth
7. Nasal tonality to the voice
8. Dysphagia to solids (if the esophagus is involved)
9. Impaired mouth movements (eg, eating, whistling, blowing, sucking)

Laboratory findings:

1. Decreased hemoglobin levels
2. Decreased iron levels
3. Decreased protein levels
4. Increased erythrocyte sedimentation rate
5. Decreased vitamin B complex levels

CYTOLOGIC STUDY CAN BE PERFORMED ON BIOPSY

Medical Care: The treatment of patients with OSMF 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 OSF present with moderate-to-severe disease. Moderate-to-severe OSF is irreversible. Medical treatment is symptomatic and aimed at improving mouth movements.

Treatment includes the following 
Steroids: In patients with moderate OSMF, weekly submucosal intralesional injections or topical application of steroids may help prevent further damage.

Placental extracts: The rationale for using placental extract (PE) in patients with OSMF derives from its proposed anti-inflammatory effect  hence, preventing or inhibiting mucosal damage.

Hyaluronidase: The use of topical hyaluronidase has been shown to improve symptoms more quickly than steroids alone. The combination of steroids and topical hyaluronidase shows better long-term results than either agent used alone

IFN-gamma: This plays a role in the treatment of patients with OSMF because of its immunoregulatory effect. IFN-gamma is a known antifibrotic cytokine.

The role of PEs, hyaluronidase, and interferon is still evolving.
Surgical Care: Surgical 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:

Nasolabial flaps and lingual pedicle flaps: Surgery to create flaps is performed only in patients with OSF in whom the tongue is not involved .
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 (Cox, 1996).

Activity: Muscle stretching exercises for the mouth may be helpful to prevent further limitation of mouth movements. 

Further Outpatient Care:

Regular physical examinations, biopsy specimen analysis, and cytologic smear testing should be scheduled to detect oral dysplasia or carcinoma, especially in patients with severe OSMF.

Patients with surface leukoplakias require close follow-up monitoring and repeat biopsies.

Patients with dysplasias and carcinomas should receive routine treatment for these entities

Complications:

Oral dysplasias and squamous cell carcinomas are complications of OSMF, the risk of developing oral carcinoma is 7.6% over a 10-year period
If the palatal and paratubal muscles are involved in patients with OSMF, conductive hearing loss may occur because of functional stenosis of the eustachian tube

Prognosis:

No treatment is effective in patients with OSMF, and the condition is irreversible . Recent reports claim improvement of the condition if the habit is discontinued following diagnosis at an early stage

Patients with OSMF have an increased risk of developing oral cancer. The malignant potential and the origin of cancer were attributed to the generalized epithelial atrophy associated with OSF

Patient Education:

1. Instruct patients regarding the importance of discontinuing the habit of chewing betel quid.
2. Inform patients that eliminating tobacco from the quid product may reduce the risk of oral cancer.
3. Instruct patients to avoid spicy foodstuffs.
4. Instruct patients to eat a complete and healthy diet to avoid malnutrition.
5. Instruct patients regarding maintaining proper oral hygiene and scheduling regular oral examinations.
6. Intervention studies and public health campaigns against oral habits linked to OSMF may be the best way of controlling the disease at the community level. Educate the community regarding the local adverse effects of chewable agents, which although not inhaled, are still not harmless.