Surgical treatment of oral submucosal fibrosis

Oral submucosal fibrosis is a serious condition that might be associated with serious complications in the affected patient. The disease also represents a major challenge to the healthcare specialists and the patient before achieving proper management of the condition. Different pharmacological and surgical interventions have been validated. However, no single modality has been proved as an adequate management approach for the disease, which is probably due to the limited number of investigations in this concern and the limited knowledge about the pathogenesis of the condition. In the present literature review, we have discussed the different surgical approaches that have been reported in the literature for managing patients with oral submucosal fibrosis. These approaches mainly aimed to remove the fibrous bands in the oral cavity and maintain adequate mouth opening. It should be noted that it would be hard to write a solid conclusion in this concern because most of the current evidence was either lacking or obtained from a limited number of studies with no proper sample sizes or adequate follow up durations. Accordingly, the indication of the surgical intervention should be primarily done by the surgeon based on the degree of involvement of the oral cavity. Finally, we recommended that further comparative investigations be carried out to further demonstrate the most appropriate management modality and to rule out whether pharmacological or surgical modalities are more efficacious in these settings.

Double tunnel technique reduces technical failure during POEM in cases with severe submucosal fibrosis

Background and study aims Submucosal fibrosis (SMF) is one of the major reasons for technical failure during per-oral endoscopic myotomy (POEM). In this study, we aimed to evaluate the impact of double tunnel technique (DT-POEM) on the technical success of POEM in cases with severe SMF. Patients and methods Data from patients with achalasia in whom SMF was encountered during POEM from Jan 2013 to Jan 2020 at our center were retrospectively evaluated. The technical success and adverse events (AEs) were analyzed and compared between cases with SMF who underwent POEM via single tunnel versus DT-POEM technique. Results A total of 1,150 patients underwent POEM during the study period. There were 14 technical failures (1.2 %). SMF and severe SMF was found in 104 (9 %) and 21 (1.8 %) patients, respectively. The majority of patients (17, 80.9 %) with severe SMF had type I achalasia. Overall, technical failures occurred in 14 cases (1.2 %) and severe SMF resulted in the majority of the technical failures (10, 71.4 %). DT-POEM was utilized in 11 cases (52.4 %) with severe SMF. The median procedure time with DT-POEM was 150 minutes (85–210). There were no major AEs and DT-POEM was technically successful in all the patients. The technical success of POEM in cases with SMF improved after the adoption of the double tunnel technique (98.4 % vs 68.3 %, P = 0.0001). Conclusions Severe SMF is the most common reason for technical failure during POEM. DT-POEM improves the technical success rates of POEM in patients with severe SMF.

Prevalence of Oral Sub Mucosal Fibrosis in Pre- Anesthesia Clinic in India: A Cross Sectional Observational Study

Introduction: Oral submucous fibrosis (OSMF) is a premalignant lesion of the buccal mucosa usually caused by chewing of betel nut, areca nut and tobacco. OSMF causes difficulty in laryngoscopy and intubation of the trachea. Patient of submucosal fibrosis do come for emergency and elective surgeries requiring general anaesthesia. In such scenario maintaining airway is a big challenge for anaesthesiologist. Knowledge of Prevalence of submucosal fibrosis in local region and degree of OSMF with difficult intubation may help anaesthesiologist to prepare and plan airway management in such conditions. Aims and Objectives: To evaluate the prevalence of oral submucous fibrosis in patients coming in pre-anaesthesia clinic and assessment of airway and prevalence of degree of OSMF by measuring Interincisal mouth opening in patients of oral submucosal fibrosis. Methods: Cross-sectional observational study was conducted in the department of anaesthesiology on 500 patients coming in pre-anaesthesia clinic. Patients were identified and sent to dental department for confirmation of diagnosis OSMF if one or more clinical feature of OSMF were present. A detailed proforma was used to record demographic parameter, the type of tobacco, betelnut and areccanut chewing habits, difficulty in mouth opening, inter incisor distance. OSMF was divided in 4 stages on the basis of inter incisor distance. Results: Prevalence rate of submucosal fibrosis patients coming in our pre-anaesthesia clinic was 8%. Thirty patients were found to be in stage 1 (75%.), nine patients were found to be in stage 2 (22.5%) and only one patient was in stage 3. Conclusion: Being aware of the prevalence of OSMF in the region and stages of OSMF in regard to inter incisor distance in pre-operative clinic helps anaesthesiologists to prepare and plan airway management. And hence surgical exploration can be avoided.

MANAGEMENT OF ORAL SUBMUCOSAL FIBROSIS (OSMF) WITH PANCHGAVYA SHUKTA SHODHAN GANDUSHA AS A DINACHARYA PROCEDURE

The rate of tobacco in addition to above conditions consumption in various forms in recent years is viewed as an emerging epidemic. The symptoms of OSMF may include burning sensation in mouth, intolerance to spicy, pain in mouth, changes in color of oral mucosa, difficulty in opening of mouth. Mukha rogas have been mentioned in Ayurved, with various treatment modalities especially Gandusha and is one of the im-portant Upakrama in Dincharya. Panchagavya is prepared by mixing five products of cow and used in tra-ditional many applications. Shukta varga includes acidic and partially alcoholic preparations of self-generated nature. Application of Panchagavya externally can reduce the Kaathinyata (Hardness) under the Twacha (skin) of oral cavity.

Egr-1 mediates low-dose arecoline induced human oral mucosa fibroblast proliferation via transactivation of Wnt5a expression

Background Arecoline is an alkaloid natural product found in the areca nut that can induce oral submucous fibrosis and subsequent development of cancer. However, numerous studies have shown that arecoline may inhibit fibroblast proliferation and prevent collagen synthesis. Results High doses of arecoline (> 32 μg/ml) could inhibit human oral fibroblast proliferation, while low doses of arecoline (< 16 μg/ml) could promote the proliferation of human oral fibroblasts. Wnt5a was found to be both sufficient and necessary for the promotion of fibroblast proliferation. Egr-1 could mediate the expression of Wnt5a in fibroblasts, while NF-κB, FOXO1, Smad2, and Smad3 did not. Treatment with siRNAs specific to Egr-1, Egr inhibitors, or Wnt5a antibody treatment could all inhibit arecoline-induced Wnt5a upregulation and fibroblast proliferation. Conclusions Egr-1 mediates the effect of low dose arecoline treatment on human oral mucosa fibroblast proliferation by transactivating the expression of Wnt5a. Therefore, Egr inhibitors and Wnt5a antibodies are potential therapies for treatment of oral submucosal fibrosis and oral cancer.