Oral Oncology 48 (2012) 200202

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Oral Oncology
journal homepage: www.elsevier.com/locate/oraloncology

Review

Proposed clinical classication for oral submucous brosis

Chandramani B. More , Sunanda Das, Hetul Patel, Chhaya Adalja, Vaishnavee Kamatchi,
Rashmi Venkatesh
Department of Oral Medicine & Radiology, K.M. Shah Dental College & Hospital, Sumandeep Vidyapeeth University, Piparia, Vadodara 391760, Gujarat, India

a r t i c l e

i n f o

Article history:
Received 6 September 2011
Received in revised form 15 October 2011
Accepted 18 October 2011
Available online 8 November 2011
Keywords:
Arecanut
Blanching
Classication of oral submucous brosis
Fibrous bands
Gutkha
OSMF
Potentially malignant disorder
Tobacco

s u m m a r y
Oral Submucous Fibrosis (OSMF) is a chronic, progressive, scarring disease, that predominantly affects
people of South Asia and South-East Asia, where chewing of arecanut and its commercial preparation
is high. Presence of brous bands is the main characteristic feature of OSMF. Based on clinical and/or histopathological features of OSMF, various classications have been put forth till date. But the advantages
and drawbacks of these classication supersedes each other, leading to perplexity. Our various studies
and clinical experience in the eld of OSMF have initiated us to propose/introduce the new clinical classication which could assist the clinician in the categorization of this potentially malignant disorder
according to its biological behaviour and hence its subsequent medical and surgical management.
2011 Elsevier Ltd. All rights reserved.

Introduction
Oral Submucous Fibrosis (OSMF) is a potentially malignant disorder (PMD) and crippling condition of oral mucosa.13 It was rst
reported by Schwartz in 1952 among ve Indian females from
Kenya and he designated the term atropica idiopathica mucosae
oris to this condition.4 In 1953, Joshi described this condition as
submucous brosis.2,5
It is a chronic insidious scarring disease of oral cavity, characterized by progressive inability to open the mouth due to loss of elasticity and development of vertical brous bands in labial and
buccal tissues. OSMF is preceded by symptoms like burning sensation of the oral mucosa, ulceration and pain. The characteristic features of OSMF are loss of pigmentation of oral mucosa, blanching
and leathery texture of oral mucosa, de-papillation and reduced
movement of tongue, progressive reduction of mouth opening
and sunken cheeks (Fig. 1). The changes of OSMF are similar to
those of systemic sclerosis (scleroderma) but are limited to oral
tissues.6
OSMF is most commonly found in the age group of 2040 years
although it can occur in any decade.4,7 It may be associated with
oral leukoplakia and other potentially malignant disorders or with
oral malignancy (Fig. 2). In South-East Asia where oral cancer is a

Corresponding author. Tel.: +91 9974900278/0265 3011220.

E-mail address: drchandramanimore@rediffmail.com (C.B. More).
1368-8375/$ - see front matter 2011 Elsevier Ltd. All rights reserved.
doi:10.1016/j.oraloncology.2011.10.011

major public health problem, over 90% of oral malignancies are

known to arise from preexisting potentially malignant lesions.8
OSMF is predominantly seen in people of South Asia and SouthEast Asia India, Bangladesh, Sri Lanka, Pakistan, Taiwan, Southern
China, etc. where consumption of arecanut or its avoured formulations or as an ingredient in the betel quid is more prevalent.7
Variations in the prevalence gures are common between different
studies, probably because of differences in the clinical criteria for
diagnosis. The prevalence rate in India is about 0.20.5% and prevalence by gender varying from 0.2% to 2.3% in males and 1.2% to
4.57% in females.9
Recent epidemiological data indicates that, the number of cases
of OSMF has raised rapidly in India from an estimated 250,000
cases in 1980 to an estimated 5 million people in 2002.2 The reasons for the rapid increase of the disease are reported to be due
to an upsurge in the popularity of commercially prepared arecanut
and tobacco preparations gutkha, pan masala, mawa, etc. in
India.
A signicant variation in the prevalence of OSMF in different
countries has also been reported. Several case-series are reported
on Asian immigrants of UK, USA, South and East Africa.7 Sporadic
cases among the non-Asians have also been reported.
The aetiology of OSMF is multifactorial but arecanut chewing is
the main causative agent.2,6,10 Once initiated, OSMF is not amenable to reverse at any stage of the disease process even after cessation of the putative causative factor of arecanut chewing.9 The
condition may remain either stationary or become severe, leaving

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Figure 1 (A) Mucositis of right buccal mucosa. (B) Blanching of soft palate and faucial pillars along with vesicles. (C) Presence of brous bands and depapillation of tongue. (D)
De-pigmentation and marble like appearance of right buccal mucosa. (E) Mucositis and blanching of labial mucosa.

Figure 2 (A and B) OSMF and distinct homogenous leukoplakia. (CE) OSMF and extensive malignant lesion on right side.

an individual handicapped, both physically and psychologically.2,7,12 The literature is replete with the clinico-pathologic presentation of OSMF. Diagnosis and staging thus becomes very
important as it affects the treatment.2,11
Numerous classications are recommended till date.13 But the
advantages and drawbacks of these classication supersedes the
other leading to perplexity. An accurate classication is seen
to be lacking where every patient can be categorized. However,
the initial diagnosis of the disease is of utmost importance, as
the treatment and prognosis greatly depends on its staging. So,
the clinical appearance holds the most important value in staging
OSMF. Histological evaluation is equally important but a gross idea
can be surely attained regarding the current stage of the disease in
a given patient so that treatment can be initiated. And hence there
is need and urge to propose new clinical classication.
We have undertaken extensive OSMF research in both, community and clinical based studies. After examining and studying more
then 4000 patients affected with OSMF, we have tried to formulate
a simple classication based on the common site of occurrence,
symptoms, other affected sites and associated lesions. This classication was implemented on trial basis in our department for more
than three years and after extensively analyzing it on numerous
patients reporting to us for treatment, it has proved to be simple,
easy and uncomplicated. Hence we put forward a new system of
classication that will assist the clinician in the categorization of
OSMF according to its biological behaviour and for its subsequent
medical and surgical management:
Proposed classication
The clinical presentation of OSMF varies in terms of site as well
as severity. Extent of brosis and mouth opening are two very
important manifestations of OSMF that cannot be overlooked. Loss
of pigmentation of oral mucosa and Stomatitis is the most commonest initial feature in OSMF. The involvement of multiple oral
sites is directly related to the severity of the condition. The proposed new classication system is as under.
I. Clinical staging
Stage 1. (S1) Stomatitis and/or blanching of oral mucosa.
Stage 2. (S2) Presence of palpable brous bands in buccal
mucosa and/or oropharynx, with/without stomatitis

Stage 3. (S3) Presence of palpable brous bands in buccal

mucosa and/or oropharynx, and in any other parts of
oral cavity, with/without stomatitis.
Stage 4. (S4)
A. Any one of the above stage along with other potentially malignant disorders e.g. oral leukoplakia, oral
erythroplakia, etc.
B. Any one of the above stage along with oral
carcinoma.
II. Functional staging
M1. Inter-incisal
M2. Inter-incisal
35 mm.
M3. Inter-incisal
25 mm.
M4. Inter-incisal

mouth opening up to or >35 mm.

mouth opening between 25 mm and
mouth opening between 15 mm and
mouth opening <15 mm.

Example S1M1, S2M3, S2M4, S3M4, S4AM2, S4BM3.

Discussion
The distinct features of OSMF are taken into consideration while
preparing this proposed classication. And they include stomatitis,
presence of palpable brous bands, inter-incisal mouth opening
and presence of potentially oral malignant disorders or oral
malignancy.
Stomatitis is the very rst symptom and signicant feature in
the initial stage of OSMF. Stomatitis includes erythematous mucosa, vesicle, mucosal ulcers and mucosal petechiae.4 The epithelial
atrophy of oral mucosa is more vulnerable for irritation. The patient invariably complains of burning sensation on eating hot and
spicy food. Burning sensation is the most initial symptom, followed
by either hyper salivation or dryness of mouth.14 Stomatitis may
also persist at any stage of OSMF.
Presence of brous band is the most distinct feature and intermediate stage of OSMF. Blanching of oral mucosa (marble-like
appearance), may be localized, diffuse or reticular and signies
the occurrence of brous bands.14 The most common and initial
site involved is buccal mucosa.11,14 The brous bands gradually become palpable in the buccal mucosa. Involvement of the soft palate
is marked by brotic change and a clear delineation of the soft pal-

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C.B. More et al. / Oral Oncology 48 (2012) 200202

ate from the hard palate as if a heavy curtain is hanging from the
hard palate.11 Uvula may be shrunken, and in extreme cases it becomes bud like or hockey stick like.8,11 The other sites of oral cavity
are affected usually at later stage. The severity of OSMF is based on
the rigidity and thickness of the mucosa and number of oral sites
involved.
The inter-incisal mouth opening is one of the important criteria
in the progression and advancement of the disease. In severe labial
involvement, the opening of the mouth is altered to an elliptical
shape and difculty to evert.11 The dense brosis involving the tissues around the pterygo-mandibular raphe causes varying degrees
of trismus. The anatomical and physiological integrity of the
underlying musculature is vital for the degree of mouth opening.
The gradual reduction in the opening of mouth makes the patient
concerned about the condition and necessitates the urge for treatment of OSMF.
OSMF is considered among the high risk PMD that progress into
cancer. An atrophic mucosa is more likely to undergo malignant
transformation and the rate of OSMF converting into malignancy
is 4.57.6%.2 The other PMD and oral malignancy are frequently
associated with OSMF, thereby suggesting the severity and progression of OSMF leading to poor prognosis. The homogenous
and nodular leukoplakia are usually associated with OSMF. The
prevalence of leukoplakia is higher in submucous brosis patients
(26%: 14%).11 Erythroplakia and Lichen planus are rarely associated with OSMF. Presence of leukoplakia with OSMF increases
the risk of oral malignancy.11

Conclusion
The proposed classication is based on our clinical observations
and extensive studies on numerous patients suffering from OSMF
with varying degrees of severity. The distinct features along with
the association of PMD and oral malignancy are taken into consideration while preparing this classication. We believe that clinicians will be able to relate this new system of classication that
will assist them in the categorization of Oral submucous brosis
and for its subsequent medical and surgical management.

Conicts of interest statement

None declared.
Acknowledgement
The authors acknowledge the inputs provided by Dr. Mukesh
Asrani in preparing this manuscript.
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