OSMF treatment depends on its clinical stage.

Based on your description, I feel this could be either stage 3 or 4. Both these stages are indicated for surgical removal of bands with any graft (buccal pad of fat most preferred).

If the patient is not willing /not medically fit for surgery, the option is to administer intralesional dexamethasone mixed with lignocaine 2% three sites per buccal mucosa, twice per week atleast for 6 weeks and mouth exercises.

Any ulceration in OSMF patients has to be biopsied to rule out any malignant changes.

Hope this helps you.

Regards,

Hi  I agree to the above mentioned treatment . In addition to this role of physiotherapy and antioxidants should be considered 

I agree with the suggested treatment for the trismus. I would prefer not to give any antioxidant drugs though diet changes should be advised. Mouth exercises are important. Lugols Iodine has been given since long back; I don't think any trial has been done on this.

Fibrotic bands can be relieved by laser followed by steroids. Surgical correction with Buccal pad fat has got lot of relapse

i have done several BFP relinings with disappointing results. Surgically, excision of fibrous bands, extraction of all third molars, bilateral coronoidectomy and bilateral nasolabial flaps for reling the raw areas is recommended followed by active physiotherapy

A combination of intralesional administration of dexamethasone with hyalase, supplementation of antioxidants and mouth opening exercises can be tried

Any studies done on the effect of antioxidants on OSMF?

I fail to find any on a short search from Pubmed.

Lycopene is an good Anita oxidant which has proven result in SMF. Good articles are available in net regarding this.

OSMF needs attention because of two reasons: 1. The problems caused by the condition per se; ie the discomfort, trismus, intolereance to warm/spicy foods etc, and general intolerance to injuries (by teeth, etc.). Many useful treatments have been suggested in the above discussion and can be considered. The problem 2. is higher risk of malignancy. This is probably related to the cause that induced the SMF. Here 'preventive approach' is needed, and I would suggest that the best is to avoid foods that cause intolerance, oral and dental care to minimise any ulceration, adequate balanced diet. I am against use of any antioxidant t supplementation in any condition associated with cancer, the simplest reason being that it may be harmful. Well cancer cells would also enjoy a good supplement!!. (Of course if there is any difficulty in eating, temporary supplements may be used for short time).  Please go through http://www.cancer.org.au/content/pdf/CancerControlPolicy/PositionStatements/PS_Betacarotene_and_cancer_risk_September_2009.pdf. What is applicable to betaCarotene may be applicable to other antioxidants.

The article Mr.Naraynan has quoted shows beta carotene does not augment cancer but should not be used in high doses. It was an Australian based study which says an increased dose may augment only lung cancer not all the cancers.

Does anyone want to do a trial in OSMF/Leukoplakia etc. and prove it? That will be taking Science to the extreme. Good sense will advocate caution in these conditions too.

Numerous trials and published results are available in medline

Dear Sunil

Let me be clear on what we are talking about.

In the case that started the discussion a patient is suffering from OSMF and wants relief. The therapist chooses the best available option for giving her relief. This may include Lycopene.  If it is the free oxygen radicals that caused the fibrosis I don't think anti-oxidants are going to reverse the fibrosis. So, I am sure its effect is due to some other activity. Lycopene has many other effects too; may be it has fibrinolytic activity.  Anyway, any increased risk of malignancy may be offset by the relief that the patient gets from the OSMF.

But, if the aim of treatment is prevention of malignancy, then you have to consider the risk of the drug, be it Lycopene or Betacarotene or any such drug, in particularly pharmaceutical form.

Here, I am sure that any drug that can increase the risk of cancer Lung, especially squamous cell cancer, has good risk of increasing oral squamous cell carcinoma too and I would not under take any trial.

AntiOxidant trial has been done in oral Leukoplakias etc. Some trials have been done in Trivandrum, where I used to work, on the basis of Stich and Rosins finding on Micronuclei reduction. The finding there and generally has been that some leukoplakias disappear, others appear and overall benefit to the patient is doubtful because most of the leukoplakia patients come because they worry that they may get cancer., and are not worried per se about the white patch. It is meaningless to give them antioxidants. Other extensive leukoplakias that are symptomatic by themselves can be and we usually treat them by surgical excision.

Relying on intermediate endpoints like MN, Leukoplakia regression as surrogate markers of cancer reduction can lead to opposite results. From antioxidant induced MN reduction the conclusion was that MNated cells are potentially malignant and their reduction indicates that cancer is being eradicated. But, one factor that they failed to think was that MN cells are dying cells and reduction in their frequency also could have been indication that such cells destined to die were being saved by the drugs and allowed to bloom into cancer.

I would be grateful if you can send me one or two publications (send the website) which categorically showed reduction in oral/other cancer in a population given an antioxidant; I dont mean reduction in intermediate markers.

Narayanan

I accept your view sir then we need to recommend banning the commercially available products . I have seen lot of studies which has definite reduction in the symptoms in oral cancer.

i remember in one of my seniors"pg thesis Dmba induced carcinogenesis in hamster pouch has showed reduced dyplastic features when anti oxidant was added in one group. Vit E  and beta carotene was added that Time

Dear Sunil

Yes. There will be three groups: A. Carcinogen-. B. Carcinogen+;  C. Carcinogen+Anti-Oxidant. Here, Group B will have highest cancer. In Group C, the Anti-oxidants protect cells from malignant transformation, and they will be helpful and needed for this as long as the exposure is present. But, I am sure, that the frequency of cancer in Group B will be more than in Group A. Why. Either because there was not complete protection or because, in some cases atleast, the antioxidants (which are mostly vitamins or some sort of essential or nonessential food) promoted the transformed cells. After all malignant cells too are born from us and they also need food and they are better than normal cells in sourcing them out from the Extracellular fluid and utilizing them more rapidly.

In the clinical context, if we want to do a similar study, we should have three/four groups: for eg. Continuing Tobacco, Tobacco users+Anti-Oxidant, Tobacco stopped and Tobacco stopped+Anti-Oxidant. When we recruit people, as a responsible doctore and as per Guidelines, it is NOT ETHICAL to ask people to continue tobacco use!! We have to ask them to stop Tobacco use, then when and where is the anti-oxidant going to act? Is it necessary? (It is like giving unexposed hamsters antioxidants; ideally there should be such a group). Moreover, the past users may have already transformed cells which will be happy with the nutrients. This is the reason why WHO is advocating against use of these in Tabs/Caps. It was present in a WHO site; I am not sure if it is still there.

As regards banning them, they are necessary for other purposes; eg. Night blindness, nutritional deficiencies, old age, etc, etc. They cannot be banned from such use.

If you meet any tobacco user who will not stop the habit, in such a person you may advise to take food with plenty of anti-oxidants; and if you don't think he will do it, then give some dietary supplement. But first advice is to stop the habit. As a policy, I never give these for canncer prevention. Anti-oxidants, just like oxygen, are double edged swords.

Narayanan Bhattathiri

Thank you sir for the explanation. It is new concept for me but definitely scientific

I was trying to see a forest as a forest instead of trees, that is all.

Start with topical ointment of steroids with antioxidants and physiotherapy. If patient shows no recovery start up with intralesional injection of dexamethasone with hyaluronidase with supplements of antioxidants. In addition to this role of physiotherapy should be considered. 

i would suggest you to please go through this article: Khanna JN, Andrade NN. Oral submucous fibrosis: a new concept in surgical management. Report of 100 cases. Int J Oral Maxillofac Surg. 1995 Dec;24(6):433-9. Though it's an old article but it has explained beautifully and scientifically about the pathogenesis of the progression of osmf. Once that concept is clear, you would be able to evaluate the different treatment modalities and their efficacy in osmf.

http://www.ncbi.nlm.nih.gov/pubmed/8636640