What is the management of oral submucosal fibrosis (OSMF)?

Management of Oral Submucous Fibrosis (OSMF)

For pain management in OSMF, NSAIDs are the first-line treatment, while antioxidants administered systemically probably improve mouth opening slightly at 3-6 months and reduce burning sensation up to and beyond 6 months. 1, 2

Initial Assessment and Risk Stratification

The severity of OSMF should be stratified based on interincisal distance (mouth opening):

• Mild cases: Interincisal distance >20 mm 1, 3
• Severe cases: Interincisal distance <20 mm 3

All patients must be counseled on immediate cessation of areca nut/betel quid chewing, as this is the primary risk factor and continued use prevents any meaningful improvement 2, 4, 3

Medical Management Algorithm

First-Line Pharmacological Treatment

For pain control:

• NSAIDs are recommended as first-line therapy for pain management 1
• Tramadol can be considered for moderate to severe pain unresponsive to NSAIDs 1
• Simple analgesics like paracetamol for mild pain, though they provide only symptomatic relief 1

For burning sensation and mouth opening:

• Antioxidants (systemic) probably reduce burning sensation VAS scores at <3 months (MD -30.92 mm), at 3-6 months (MD -70.82 mm), and at >6 months (MD -27.60 mm) 2
• Antioxidants may increase interincisal distance at <3 months (MD 3.11 mm) and probably increase it slightly at 3-6 months (MD 8.83 mm), though these improvements are below the 10 mm threshold considered clinically meaningful 2
• Pentoxifylline may increase mouth opening slightly (MD 1.80 mm) 2

Second-Line Medical Options

Intralesional injections:

• Combination of dexamethasone and hyaluronidase administered submucosally has been used, though evidence is very uncertain 2, 3
• Conservative oral vitamin B-complex with buflomedial hydrochloride and topical triamcinolone acetonide 0.1% provides symptomatic relief in mild cases but only in the short term 3

Important caveat: Medical treatments combined (oral vitamins + intralesional injections) are satisfactory for mild impairment (ID >20 mm) but lead to symptomatic relief only in the long term, not structural improvement 3

Surgical Management

Indications for surgery:

• Severe limitation with interincisal distance <20 mm 3
• Failure of medical management in advanced cases 3

Surgical approach:

• Excision of fibrotic tissues with coverage using buccal fat pad (BFP) grafts is particularly successful in diminishing scarring after 2 years compared to split-thickness skin or fresh human amnion grafts 3
• Surgical therapy leads to significant improvement of trismus in severe cases when combined with cessation of betel quid chewing and daily mouth opening exercises 3

One serious caveat: One study evaluating abdominal dermal fat graft reported serious adverse effects resulting in prolonged hospital stay for 3/30 participants 2

Adjunctive Therapies

Physiotherapy:

• Daily forcible mouth opening exercises are necessary both before and after any therapy to manage OSF cases in early and advanced stages 4, 3
• Mouth opening exercises led to improvement in a 12-year-old patient who ceased betel nut chewing, though tongue protrusion remained unaltered 4

Alternative herbal formulations:

• A novel herbal paste of turmeric, tulsi, and honey showed statistically significant improvement in mouth opening, tongue protrusion, burning sensation, blanching, and reduction in palpable fibrous bands compared to antioxidant placebo, though this requires further validation 5

Treatment Algorithm by Disease Severity

For mild cases (ID >20 mm):

1. Immediate cessation of areca nut/betel quid chewing 2, 4, 3
2. NSAIDs for pain management 1
3. Systemic antioxidants for burning sensation and modest mouth opening improvement 2
4. Daily mouth opening exercises 4, 3
5. Consider combination oral vitamins + topical triamcinolone for symptomatic relief 3

For severe cases (ID <20 mm):

1. Immediate cessation of areca nut/betel quid chewing 2, 4, 3
2. NSAIDs or tramadol for pain 1
3. Trial of systemic antioxidants + intralesional dexamethasone/hyaluronidase 2, 3
4. If medical management fails: surgical excision with BFP grafting 3
5. Mandatory daily mouth opening exercises post-operatively 3

Critical Monitoring and Follow-Up

• Monthly examinations for at least 2 years are necessary to monitor response and detect malignant transformation 3
• OSMF transforms into malignant tumor in 1.5-15% of all cases, making long-term surveillance essential 6
• Symptoms include submucous fibrosis, ulceration, xerostomia, burning sensation, and restricted mouth opening, all of which greatly interfere with quality of life 6

Evidence Quality Considerations

The evidence base for OSMF management is limited: only moderate-certainty evidence exists for systemic antioxidants improving mouth opening at 3-6 months and burning sensation up to and beyond 6 months 2. All other interventions have low or very low-certainty evidence 2. The surgical evidence comes from a single 10-year retrospective case series, not randomized trials 3. Despite these limitations, the combination of habit cessation, medical management for mild cases, and surgical intervention for severe cases with mandatory physiotherapy represents the current standard of care based on available evidence.