Oral Submucous Fibrosis Treatment Guide

ORAL SUBMUCOUS FIBROSIS
AND ITS MANAGEMENT
Maxfac
Center for Cranio - Maxillofacial & Head and Neck Surgery, Siliguri
Contact us at : maxfacmail@gmail.com
Mentor & Guide :
Dr Saikat Saha MDS OMFS
Presenter : Dr Mukesh Chhetri BDS
Fellow Trainee at Maxfac

CONTENTS
• Introduction
• Definition
• WHO definition of precancerous condition
• Epidemiology
• Etiology/Predisposing factors
• Common products
• Symptoms
• Signs
• Diagnostic measurements
• Constituents of arecanut
• Pathogenesis
• Histopathology
• Staging
• Blood chemistry & hematological variations
• Management
• Surgical management
• An overview
• Conclusion
• Reference

INTRODUCTION
• Oral Submucous Fibrosis is a chronic debilitating
disease characterized by gradually increasing
fibrosis of the oral cavity and pharynx, mainly the
buccal mucosa, resulting in trismus.
• Most treatment modalities in OSMF have
centered on release of the fibrotic bands to assist
oral opening and some to provide symptomatic
relief to the patient.

DEFINITION
"An insidious chronic disease affecting any
part of the oral cavity and sometime the
pharynx. Although occasionally preceeded
by and/or associated with vesicle formation,
it is always associated with juxta-epthelial
inflammatory reaction followed by fibro-
elastic change of lamina propria, with
epithelial atrophy leading to stiffness of the
oral mucosa and causing trismus and
inability to eat" -Pindborg (1966)

Diffuse oral submucous fibrosis
Idiopathic scleroderma of mouth
Idiopathic palatal fibrosis
Sclerosing stomatitis
Juxtaepithelial fibrosis
Also called:

Upper Digestive Tract
Submucous fibrosis
Pharynx

WHO Definition of
‘Oral Precancerous Condition’
“A generalized pathological state of the oral mucosa
associated with a significantly increased rick of cancer”–
accords well with the characteristics of OSF

• VIDARI ~ 600AD (Sushruta)
• Atrophia Idiopathica (tropica)
Mucosae Oris ~ Schwartz(1952)
• Oral Submucous Fibrosis ~ Joshi(1953)

EPIDEMIOLOGY
• Adolescents and adults (16 – 35 years)
• 0.2 – 0.5 % prevalence rate in India.

ETIOLOGY / PREDISPOSING FACTORS
(multifactorial)
ARECANUT & PRODUCTS
TOBACCO
CHILIES(CAPSAICIN)
GENETIC & IMMUNOLOGICAL PROCESSES
NUTRITIONAL DEFICIENCIES
SMOKING
ALCOHOL
MISI (BLACK POWDER USED BY WOMEN IN U.P.)

COMMON PRODUCTS
BETEL QUID
(areca nut, tobacco, slaked lime and other species)

TOBACCO PREPARATIONS
Gutkha, Pan Masala, Mawa, Flavoured Supari, Khaini etc.

MISI
(sodium bicarbonate, alum, myrobalan charcoal and filler earth)

Symptoms
• Burning sensation
• Difficulty in mouth opening
• Difficulty in swallowing
• Taste changes
• Dryness of mouth
• Excessive salivation
• Difficulty in speaking
• Vesicles & Ulcers
• Hearing difficulty
• Hoarseness of voice
• Nasal twang

Signs
• Blanching of oral mucosa
• Presence of fibrous bands
• Leathery texture of oral mucosa
• Trismus
• Restriction of Tongue Movements
• Blisters/Erythematous areas/ Ulcers/Vesicles/Erosions
• Depapillation of Tongue
• Shrunken/Deviated/Bud like Uvula
• Atrophic tongue
• Bilateral pouching-in while opening mouth/Sunken cheeks
• Lymphadenopathy
• Anaemia
• Secondary/Malignant changes

Presence of fibrous bands
Blanching of oral mucosa

Leathery texture of oral mucosa

Trismus
Restriction of Tongue Movements

Erosions
Vesicles
Ulcers
Blisters/ Erythematous areas

Depapillation of Tongue
Atrophic tongue

Bud like Uvula
Shrunken Uvula
Deviated Uvula

Bilateral pouching-in while opening mouth / Sunken cheeks
Angular cheilitis

Secondary Changes
Malignancy
Leukoplakia Erythroplakia

DIAGNOSTIC MEASUREMENTS
INTERINCISAL DISTANCE (MAXIMUM MOUTH OPENING)
Normal distance between Central Incisor Tips:
Males:
35 to 45 mm
Females:
30 to 42 mm

TONGUE PROTRUSION
Normal Mesio-Incisal Angle of the Upper Central Incisor to the Tip of the Tongue when
maximally extended with the mouth wide open:
Males:
5 to 6 cm
Females:
4.5 to 5.5 cm

CHEEK FLEXIBILITY: CF= V1-V2
.
V2- Point measured
between at one-third the
distance from the angle of
the mouth on a line
joining the tragus of the
ear to the angle of the
mouth
The patient is then asked to
blow his cheeks fully and the
distance between the two
points is marked on the
cheek as V1
Mean values for
cheek flexibility:
Males
35 to 45 mm
Females
30 to 40 mm
[Patil S. and Maheshwari S.(2014)]

1/3
V2
V1
1/3
When normally
When cheeks fully blown

StageI:EarlyOSMF
•IID
•TP
•CF
StageII:ModerateOSMF
•IID-
↓33%
•TP-
↓33%
•CF-
↓33%
StageIII:SevereOSMF
•IID-
↓66%
•TP-
↓66%
•CF-
↓66%
[Bailoor D.N. (1993)]

QUID
“A substance or mixture of substances, placed
in the mouth or chewed or remaining in
contact with the mucosa, usually containing
one or both of the two basic ingredients
tobacco and/or arecanut, in raw or any
manufactured or processed form”

ARECA NUT
ALKALOIDS FLAVANOIDS
 ARECOLINE
 ARECAIDINE
 ARECOLIDINE
 GUYACOLINE
 GUACINE
 TANNINS
CATECHINS

ALKALOIDS (Arecoline)
NITROSATION
N-NITROSAMINE
CYTOTOXIC EFFECTS

PATHOGENESIS [P.Rajlalitha, S.Vali (2005)]
COLLAGEN PRODUCTION PATHWAY COLLAGEN DEGRADATION PATHWAY

Initial events of the disease
Oral
mucosa
Betel quid
habit
Chronic
inflammation
Activated T cell &
Macrophage at
the site
Constant
irritation
↑Cytokines &
Growth factors
Duration &
Frequency
of habit
Deficiency
of Iron &Vit.
B12
mechanical
chemical
15 MINS -
HOUR X 5-6
TIMES A DAY

COLLAGEN PRODUCTION PATHWAY
ACTIVATION OF PRO-COLLAGEN GENES
ELEVATION OF PROCOLLAGEN PROTEINASES LEVELS
PNP PCP
UPREGULATION OF LYSYL OXIDASE(LOX) ACTIVITY

COLLAGEN DEGRADATION PATHWAY
ACTIVATION OF TISSUE INHIBITOR OF MATRIX
METALLOPROTEINASE GENE(TIMPs)
ACTIVATION OF PLASMINOGEN ACTIVATOR
INHIBITOR GENE(PAI)

OVER ALL EFFECT
INCREASE IN COLLAGEN
PRODUCTION
DECREASE IN
COLLAGEN
DEGRADATION
INCREASED COLLAGEN
(INSOLUBLE FORM— CROSS-LINKING
OF INSOLUBLE COLLAGEN)
FIBROSIS
ORAL SUBMUCOUS FIBROSIS

HISTOPATHOLOGY
EARLY STAGE ADVANCED STAGE

STAGING
Chandramani B. More et al (2011)
CLINICAL STAGING

Stage 4 (S4)
• Any one of the
above stage with
other PMDs (oral
leukoplakia, oral
erythroplakia, etc)
• Any one of the
above stage along
with oral
carcinoma.

FUNCTIONAL STAGING
Interincisal
mouth
opening:
≥ 35 mm.
Interincisal
mouth
opening:
15 — 25 mm.
Interincisal
mouth
opening:
< 15 mm
Interincisal
mouth
opening:
25 – 35 mm.
M 1
M 4
M 2
M 3

BLOOD CHEMISTRY &
HEMATOLOGICAL VARIATIONS
↓ Vit. B12
↓ Serum
Albumin
↓Fe
↓ Folate
Slight
Eosinophilia
↑
Gammaglobulin
↑ TIBC
Microcytic
Hypochromic
Anaemia↑ESR
Macrocytic
Normochromic
Anaemia

ELIMINATION OF HABITS
NUTRITIONAL SUPPORT
IMMUNO-MODULATORY
DRUGS
LOCAL DRUG DELIVERY
INTRALESIONAL INJECTIONS
PHYSIOTHERAPY
INTERFERON GAMMA-1 D
(IMMUNOKINE OF BOEHRINGER)
COMBINED THERAPY
MOUTH RINSES
SURGICAL MANAGEMENT

BETEL QUID
CHEWING HABIT
CHRONIC
INFLAMMATORY PROCESS
TGF-β
COLLAGEN
PRODUCTION
COLLAGEN
DEGRADATION
TIMPPCPPNP PLASMINOGEN
ACTIVATOR
SYSTEM
COLLAGENASE
-
-
-
-
1. Anti-inflammatory/
Immune-modulatory drugs
2. Anti- TGF-β
3. Cu Chelators
4. Anti-LOX
drugs
5. Collagenase
activators +
LOX
(Lysyl
Oxidase)

Type Drug
ANTI-INFLAMMATORY /
IMMUNE-MODULATORY
DRUGS
Pirfenidone
(ESBRIET, INTERMUNE)
(immunosuppressant)
IFN-gamma (immunoregulatory
cytokine)
Still in research
200 µg/ml have been
tried
ANTI- TGF-Β Mouse monoclonal
antibodies:
Anti-TGF-β1 (8A11)
(NovusBio®, USA) (Cat No: NB110-
59988)
Anti-TGF-β2 (TB21)
(NovusBio®, USA) (Cat No: NBP1-
51749)
Dilution:
4 μl/100 μl
(for anti-TGF-β1)
1 μl/100 μl
(for anti-TGF-β2)
CU CHELATORS Penicillamine Still in research
ANTI-LOX DRUGS β-aminopropionitrile
(BAPN, 100 µM)
an irreversible LOX inhibitor
Still in research
COLLAGENASE ACTIVATORS Colchicine 0.5 mg orally twice
a day

As gum, skin patch, nasal spray, or inhaler.
Chewing gums Skin Patch

Bupropion Hydrochloride (ZYBAN)
Varenicline (CHANTIX)
ZYBAN prescribed under another name“WELLBUTRIN” to treat depression.
As tablets

HIGH PROTEINS & HIGH- CALORIE DIET
VITAMIN B COMPLEX & OTHER VITAMINS
MINERALS
Intake of red tomatoes, fresh foods, green leafy vegetables
Green tea
Routine Hb % levels followed by Iron supplementation
LYCOPENE

DRUG NAME BRAND NAME DOSAGE CLASSIFICATION
Lycopene LYCOPENE (NOW)
(lycopene ~10mg)
SM FIBRO
(lycopene ~5mg)
LYCOSTAR
(Lycopene~5000mcg)
8 – 10 mg
Twice daily
For 2 months
(16mg in
2 divided doses)
Powerful antioxidant
obtained from
tomatoes
Manufactured by the
Lyc-O-Mato™
process

MECHANISM OF ACTION ADVERSE
EFFECTS
Reducing the free radical
reaction
That can cause DNA mutations and
changes in lipid peroxidation of
cellular membranes and changes in
enzymatic activities
Generally well
tolerated.
The scientific literature
documents some GI
complaints

Topical Application:
TRIAMCINOLONE GEL 0.1% (Kenacort) / TRIAMCINOLONE IN ORA-BASE
BETAMETASONE 0.5% (Betnesol)
KENALOG S EYE OINTMENT
(triamcinolone acetonide 1 mg, gramicidin 0.25 mg, neomycin sulphate 2.5 mg/1 g)
IN EARLY STAGES
3-4
TIMES
A DAY

GLUCOCORTICOIDS & PLACENTAL EXTRACTS
(LOCAL & SYSTEMIC APPLICATION)
SUPPRESS INFLAMMATORY RECATION
PREVENT FIBROSIS
Placentrix injection intralesionally (Aqueous extract)
Levamisole (Dewormis)
Pentoxifylline (Trental)

Levamisole DEWORMIS
BIOVAM
LEVOMOL
150 mg
Three times daily
Three consecutive days
in a week
Three alternate weeks
Or,
In combination with
Two capsules of
Antaoxid daily
For Six weeks.
Anthelminthic drugs

MECHANISM OF ACTION ADVERSE EFFECTS CONTRAINDICATIONS
Immunomodulator
(modifies both cellular
and humoral immunity)
In OSF it reduces the
level of IgG, IgA and IgM
thus slow down the
chronic inflammatory
process
CENTRAL NERVOUS
SYSTEM
Memory loss, loss of
consciousness
MISCELLANEOUS
Muscle weakness
Pre-existing blood
disorders
Pregnancy and lactation
Inflammation of joints
Severe kidney problems

Pentoxyfylline TRENTAL-400
FLEXITAL 400mg SR
tabs
400 mg TDS
For 6-7 months
Peripheral
Vasodilators
(Methylxanthine
derivative)

MECHANISM OF
ACTION
ADVERSE EFFECTS CONTRAINDICATIONS
It increases mucosal
vascularity.
Anti inflammatory
properties
Immuno-modulating
actions
Nausea, Vomiting,
Dyspepsia, Bloating
Severe allergic
reactions
Allergic to any
ingredient in
Pentoxifylline /
Methylxanthines
(eg, theophylline,
caffeine, theobromine)
Recent bleeding in
the brain or eye

INTERFERON GAMMA-1 D
(IMMUNOKINE OF BOEHRINGER)

200 µg/ml have been tried (Anti-fibrotic cytokine)
Adverse effects: Fever, chills, headache, myalgia, arthralgia, injection site reactions
Contraindication: Severe hepatitis, renal impairment & cardiac disease.

Interferon γ
(intralesional injection)
ACTIMMUNE (0.01- 10.0 U/mL)
3 times daily
For 6 months
or,
(50 mg / 0.25 ml)
Twice a week
8 weeks
Anti-fibrotic
cytokine

MECHANISM OF
ACTION
Regulation of
fibroblast
proliferation &
collagen synthesis
Upregulation of
antifibrotic cytokine
and collagen
synthesis in the basal
layer of epithelium
and lamina propria
Fever
Chills
Headache
myalgia
Arthralgia
injection site reactions
Severe hepatitis
Renal impairment
Cardiac disease

Listerine Mouthwash
Essential Oils :
Menthol (mint) 0.042%
Thymol(thyme) 0.064%
Methyl Salicylate (wintergreen) 0.06%
Eucalyptol (eucalyptus) 0.092%
With
Powdered Dexamethasone tablet (2mg in 5mL)
3 – 4 times a day

(IN MODERATE PHASE)
ENZYMES GLUCOCORTICOIDS AQEOUS EXTRACT
HYALURONIDASE
CHYMOTRIPSIN
COLLAGENASE
SHORT ACTING
HYDROCORTISONE
INTERMEDIATE ACTING
TRIAMCINOLONE ACETONIDE
LONG ACTING
DEXAMETHASONE SODIUM PHOSPHATE
BETHAMETHASONE SODIUM PHOSPHATE
PLACENTAL EXTRACT

ENZYMES
HYALURONIDASE

Hyaluronidase
HYNIDASE
HYA
1500 IU (0.5-2 ml)
With 2% lignocaine
Twice daily
For 10 weeks
Hydrolytic enzyme

MECHANISM OF ACTION ADVERSE EFFECTS CONTRAINDICATIONS
Breaks down Hyaluronic
acid
(Depolymerizing)
Lowers the viscosity of
intracellular substances
Decreases collagen
formation
Local Injection site
reactions such as
Pain
Itching
Redness
Swelling
Urticaria,
Angioedema
(in less than 0.1% )
Hypersensitivity to
Hyaluronidase

ENZYMES
CHYMOTRIPSIN

Chymotripsin
TRYPSIN
CHOMISIN
CHYMASE
CHYMOTRIP
5000 IU
Twice a week
For 10 weeks
Proteolytic enzyme
Anti-inflammatory
agent

MECHANISM OF ACTION ADVERSE EFFECTS
Endopeptidase
Hydrolyses peptide
bonds and esters
Local: Injection site
reaction
Allergic reactions rare

COLLAGENASE
ENZYMESINTRALESIONAL INJECTIONS

Collagenase
XIAFLEX
SANTYL
COLLAGENASE
SANTYL
2mg of collagenase
materials dissolved
in 1ml of distilled
water
Lysosomal enzyme

MECHANISM OF
ACTION
ADVERSE EFFECTS
Degrading,
Phosphate esters
Proteins
Polysaccharides
Glycosides
Sulphate Esters
Pain
Swelling
Trismus

HYDROCORTISONE
(SHORT ACTING)
GLUCOCORTICOIDSINTRALESIONAL INJECTIONS

Hydrocortisone
WYCORT
EFCORLIN
CORT-S
MOSACORT
25 mg/ml
(1.5cc)
Once a week
For a duration of 12
weeks
Short acting
Glucocorticoid
(t½ < 12 hours)

TRIAMCINOLONE
ACETONIDE
(INTERMEDIATE ACTING)

Triamcinolone
acetonide
KENACORT
TRICORT
P-CORT-40
KENALOG-40
40 mg/ml
(1.5cc)
Once a week
For a duration of 12
weeks
Intermediate acting
Glucocorticoid
(t½ > 12-36 hours)

DEXAMETHASONE SODIUM
PHOSPHATE
(LONG ACTING)

Dexamethasone
sodium phosphate
DECADRON
PHOSPHATE
DEXONA
WYMESONE
DECDAN
DEXASONE
4 mg/ml
(0.5-1 ml bilaterally)
At multiple sites
Once a week
For 6 weeks
Long acting
Glucocorticoid
(t½ > 36 hours)

MECHANISM OF
ACTION
Anti inflammatory
action
Inhibits the
proliferation of
fibroblasts
Immunosuppressive
action
Cushing habitus
Suppression of
Hypothalamo-
Pituitary-
Adrenal(HPA) axis
Hyperglycemia
Recent myocardial
infarction
Osteoporosis
(post-menopausal females
are particularly at risk)
Peptic ulcer
HTN/CHF
Renal failure

BETAMETHASONE SODIUM
PHOSPHATE
(LONG ACTING)

Betamethasone
sodium phosphate
BETNESOL
BETACORTRIL
CELESTONE
BETAGIN
4 mg/ml
(0.5-1 ml bilaterally)
At multiple sites
Once a week
For 6 weeks
Long acting
Glucocorticoid
(t½ > 36 hours)

MECHANISM OF ACTION
Anti inflammatory action
Inhibits the proliferation of
fibroblasts
Immunosuppressive action

PLACENTAL EXTRACT
AQEOUS EXTRACTINTRALESIONAL INJECTIONS

Placental extract
PLACENTREX 2 ml
Once a week
For 10 weeks
Biogenic stimulants
Aqueous extract of
human placenta

MECHANISM OF
ACTION
Anti-inflammatory and
significant analgesic
effect
Increase in blood
circulation and tissue
vascularity
Arrest of tissue growth
stagnation
Lower immune
response factor
Local: Injection site
reaction
Hypersensitivity to
placental extract

BETEL QUID
CHEWING HABIT
CHRONIC
INFLAMMATORY PROCESS
TGF-β
COLLAGEN
PRODUCTION
COLLAGEN
DEGRADATION
TIMP
LOX
(Lysyl
Oxidase)
PCPPNP PLASMINOGEN
ACTIVATOR
SYSTEM
COLLAGENASE
5. Collagenase
activators +

Colchicine COLCHINDON
GOUTNIL
ZYCOLCHIN
0.5 mg orally
Twice a day
Antigout agent
Collagenase
activators

MECHANISM OF
ACTION
ADVERSE EFFECTS DRUG INTERACTIONS
Disruption of the
microtubule
formation and
Depolymerizes
microtubules which
prevent the Extrusion
of collagen fibers
from the fibroblast
and increases
Collagenolytic activity
Dose related
Overdose:
Kidney damage
CNS Depression
Chronic Therapy:
Aplastic anaemia
Azole antifungals
(Itraconazole,
Ketoconazole)
Macrolide antibiotics
(Clarithromycin,
Erythromycin)
Can affect the removal
of colchicine from your
body

SEVERE PHASE
SUBMUCOSAL RESECTION OF FIBROUS BANDS (FIBROTOMY)
BILATERAL TEMPORALIS MYOTOMY or CORONOIDECTOMY
NASOLABIAL FLAP OR LINGUAL PEDICAL FLAP
SPLIT SKIN GRAFT / MUCOSAL GRAFT
BUCCAL PAD OF FAT
COLLAGEN

MOUTH OPENING EXCERCISES
USE OF APPLIANCE (HEISTER’S JAW OPENER)
STICK BALLOONING
HEAT THERAPY
MOUTH OPENING EXERCEISES USING WOODEN SPATULA / ICE CREAM STICKS
MOUTH GAG/ ACRYLIC SURGICAL SCREW

VASODILATORS
PENTOXYFYLLINE
NYLIDRIN HYDROCHLORIDE
VITAMIN D, E, B-COMPLEX
IODINE
PLACENTAL EXTRACT
LOCAL & SYSTEMIC
CORTICOSTEROIDS
PHYSIOTHERAPY

IMMUNISED COW MILK
SKIMMED MILK FORM COW IMMUNISED WITH MULTIPLE HUMAN INTESTINAL BACTERIA
VIT A, C , B1, B2 , B6, B12, NICOTINIC ACID, PANTHOTENIC ACID, FOLIC ACID, IRON, COPPER, ZINC
20-30% HIGHER IgG ANTIBODY
2L DAILY / 45g MILK POWDER TWICE DAILY FOR 3 MONTHS

TURMERIC
(Curcuminoids)
TURMERIC OIL & OLEORESIN
IN VITRO FREE RADICAL SCAVENGER

INJ OF GOLD, VITAMIN A & COLLAGENASE
CHEMOTHERAPEUTIC AGENTYS LIKE TOPICAL
BLEOMYCIN

DIATHERMY
Microwave diathermy
Low current (20 Watts x 2450 cycles)
Early – Moderate stage

ULTRASOUND
Efficient deep heating modality
(Frequency 0.8-1 MHz Intensity 0.5-3 w/sq.cm)

AN OVERVIEW
J Maxillofac Oral Surg. 2015 Sep; 14(3): 521–531.

Palatal island flap based on
greater palatine artery (contd.)
J N Khanna, N N Andrade

ANTERO-LATERAL THIGH (ALT)
FLAP (Huang et al)

CONCLUSION
• OSF is one of the most poorly understood and unsatisfactorily treated
diseases.
• Among the above mentioned modalities for treatment of OSF none of
them can be considered to be completely effective.
• All available treatments provide symptomatic relief, which is short lived.
• This is mainly due to the fact that the etiology of the disease is not fully
understood and the disease is progressive in nature.
• The wide range of treatment modalities currently used for OSF is ample
evidence that there is no simple answer to how it should be managed.
• Therefore, an evidence based practice will help to provide the best
possible treatment for the disease.

References
• Shafer’s Textbook of Oral Pathology(seventh edition)~ Shafer, Hine, Levy. Editors- R Rajendran, B Sivapathasundharam.
• DIAGNOSTIC ORAL MEDICINE (first edition, 2013)- B K Venkataraman (Chief Editor); Asha R Iyengar, K S Ganapathy, C V Mohan, K S
Nagesh (Associate Editors).
• Venkatesh V. Kamath. Surgical Interventions in Oral Submucous Fibrosis: A Systematic Analysis of the Literature. J Maxillofac Oral
Surg. 2015 Sep; 14(3): 521–531.Published online 2014 Dec 25. doi: 10.1007/s12663-014-0639-3.Available at
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4510093/
• Kumar L. K. Surej, Nikhil M. Kurien, and Nasil Sakkir. Buccal fat pad reconstruction for oral submucous fibrosis. Natl J Maxillofac Surg.
2010 Jul-Dec; 1(2): 164–167. doi: 10.4103/0975-5950.79222. Available at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3304196/.
• P. Rajalalitha, S. Vali. Molecular pathogenesis of oral submucous fibrosis- a collagen metabolic disorder(Review article). J Oral Pathol
Med. 2005 Jul;34(6):321-8.
• More C B, Gupta S, Joshi J, Varma S N. Classification system of Oral Submucous Fibrosis(Review article). J Indian Aca Oral Med Radiol
2012;24(1):24-29.
• Vikas Berwal, Monika Khangwal, Ravinder Solanki, Rakshit Khandeparker, Kiran Savant, Omkar Shetye. CLASSIFICATION SYSTEMS FOR
ORAL SUBMUCOUS FIBROSIS- FROM PAST TO PRESENT: A REVIEW. Berwal V. et al., Int J Dent ealth Sci 2014; 1(6):900-913.
• Harsha Pradhan, Hemant Gupta, VP Sinha, Sumit Gupta, MC Shashikanth. Two wound-covering materials in the surgical treatment of
oral submucous fibrosis: a clinical comparison. Journal of Oral Biology and Craniofacial Research 2012 April Original Article Volume 2,
Number 1; pp. 10–14. doi: 10.1016/S2212-4268(12)60004-9. Available at
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3941626/pdf/main.pdf
• Shobha Nataraj, Yadavalli Guruprasad, Jayaprasad N.Shetty. A Comparative Clinical Evaluation of Buccal Fat Pad and Collagen in
Surgical Management of Oral Submucous Fibrosis. Archives of Dental Sciences, Vol.2, Issue 4, 17-24 (http:www.archdent.org).
Available at
https://www.researchgate.net/publication/232702355_A_Comparative_Clinical_Evaluation_of_Buccal_Fat_Pad_and_Collagen_in_Surg
ical_Management_of_Oral_Submucous_Fibrosis

• Venkatesh Viswanath Kamath, Shruti Krishnamurthy, Krishnanand P. Satelur, and Komali
Rajkumar. Transforming growth factor-β1 and TGF-β2 act synergistically in the fibrotic
pathway in oral submucous fibrosis: An immunohistochemical observation. Indian J Med
Paediatr Oncol. 2015 Apr-Jun; 36(2): 111–116. doi: 10.4103/0971-5851.158842. Available at
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4477373/
• L. Ashok, G. P. Sujatha. Targeted therapy for oral submucous fibrosis - Future
strategies. Journal of Medicine, Radiology, Pathology & Surgery ● Vol. 1:6 ● Nov-Dec
2015.
• Usha Dayanarayana, Nagabhushana Doggalli,Karthikeya Patil, Jai Shankar, Mahesh K.P, Sanjay. Non
surgical approaches in treatment of OSF. IOSR Journal of Dental and Medical Sciences (IOSR-
JDMS) e-ISSN: 2279-0853, p-ISSN: 2279-0861.Volume 13, Issue 11 Ver. III (Nov. 2014), PP 63-69
www.iosrjournals.org.
• Manas Gupta, Pankaj Mishra ,Kirti Shrivastava ,Neha Singh ,Pushpraj Singh. Oral Submucous
Fibrosis- Current Concepts of Aetiology & its Management(Review article). Journal Of Applied
Dental and Medical Sciences 1(1);2015 28-39. Available online at www.joadms.org

Thank You
Maxfac
Center for Cranio - Maxillofacial & Head and Neck Surgery, Siliguri
Contact us at : maxfacmail@gmail.com
Mentor & Guide :
Dr Saikat Saha MDS OMFS
Presenter : Dr Mukesh Chhetri BDS
Fellow Trainee at Maxfac

Oral Submucous Fibrosis Treatment Guide

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