Treatment of Oral Submucous Fibrosis
Definitive Recommendation
For oral submucous fibrosis (OSMF), treatment should be stratified by severity: mild cases (interincisal distance >20mm) respond to medical management with intralesional corticosteroids combined with hyaluronidase plus oral antioxidants, while severe cases (interincisal distance <20mm) require surgical excision of fibrotic bands with buccal fat pad grafting, which demonstrates superior long-term outcomes compared to other graft materials. 1
Treatment Algorithm by Disease Severity
Mild OSMF (Interincisal Distance >20mm)
Medical management is the first-line approach:
- Intralesional therapy with dexamethasone combined with hyaluronidase provides symptomatic relief and functional improvement 1, 2
- Add oral supplementation with vitamin B-complex and topical triamcinolone acetonide 0.1% to the intralesional regimen 1
- Combination therapy with lycopene plus corticosteroids and hyaluronidase ranks highly for improving mouth opening (mean difference 7.07mm) 3
- Aloe vera ranks first for reducing burning sensation (mean difference 6.14mm), followed by corticosteroids with antioxidants 3
Severe OSMF (Interincisal Distance <20mm)
Surgical intervention becomes necessary when medical management fails:
- Excision of fibrotic bands followed by interpositional grafting is required for significant trismus 1, 4
- Buccal fat pad (BFP) grafting is the preferred graft material, demonstrating superior outcomes with diminished scarring at 2-year follow-up compared to split-thickness skin or amnion grafts 1
- Alternative grafts include fresh human placental grafts for resistant cases 2
- Surgical therapy leads to significant improvement in severe limitation cases where medical management provides only symptomatic relief 1
Essential Adjunctive Measures
These interventions are mandatory regardless of treatment modality:
- Cessation of betel quid chewing before and after therapy is necessary for treatment success 1
- Daily mouth opening exercises must be performed continuously to maintain gains 1
- Monthly follow-up examinations for at least 2 years are required to monitor progression and malignant transformation risk 1
Alternative Medical Agents
When standard therapy is insufficient or not tolerated:
- Oxitard (herbal formulation) ranks as the most efficacious agent for improving mouth opening (mean difference 10.29mm) 3
- Chymotrypsin combined with hyaluronidase and dexamethasone shows success in local injection protocols 2
- Pentoxifylline, nylidrin hydrochloride, iron supplements, and lycopene have been studied but lack high-quality evidence 5
Critical Caveats
Important limitations in the evidence base:
- Medical therapy provides symptomatic relief only in the long term for mild cases, not disease reversal 1
- Most studies lack methodological rigor with small sample sizes, short follow-up periods, and no standardized protocols 5, 4
- The choice of surgical procedure is often determined by operator preference rather than evidence-based protocols 4
- Malignant transformation risk necessitates long-term surveillance regardless of treatment success 1, 5
Treatment Selection Pitfalls to Avoid
- Do not rely on medical management alone for severe trismus (ID <20mm)—these patients require surgical intervention 1
- Do not use split-thickness skin or amnion grafts when buccal fat pad is available, as BFP shows superior long-term scarring outcomes 1
- Do not proceed with any treatment without ensuring betel quid cessation, as continued use negates therapeutic benefits 1
- Do not discharge patients after initial improvement—minimum 2-year follow-up is essential given malignancy risk 1