CASE

PRESENTATION
Resource faculties:
Prof. Dr. Jyotsna Rimal (HoD)
Presenter :
Dr. Iccha Kumar Maharjan (Associate Prof.)
Sagar Adhikari
Dr. Pragya Regmee (Assistant Prof.) JR- II

Department of Oral Medicine and Radiology

 Demographic Details

• Name: Pramod Sitaula Marital status: Unmarried

• Age/ Gender: 28yrs/M Patient ID number:
• Address: Damak-11
3205038
• Occupation: Student
Phone number:
• Religion: Hindu
9819082023
• Date: October 14, 2018
SES: Upper middle 2
 Chief complain
• Complain of difficulty in opening mouth since 1 month.

3
 History of presenting illness
• Apparently well 1 month back when he noticed he could not fully open
his mouth, while having food, which was gradually progressive in nature.
• History of burning sensation (NRS: 6/10) since 1 month. It was insidious
in onset, gradually progressive, persistent throughout the day,
aggravated with hot and spicy foods, no relieving factors documented.
• History of difficulty in swallowing present since 1 month.
• History of occasional blister formation which ruptures leading to
formation of wound inside mouth.
4
• No history of trauma.
• No history of dry mouth.
• No history of tooth pain in and around the area prior to decrease in
mouth opening.
• No history of fever.
• No history of joint noise in front of ear.
• No history of significant weight loss.
• No history of similar problem before.
• No history of similar problem present in other members of family.
• No history of altered bowel and bladder habit.
• No history of any medical/dental consultation done for the problem. 5
Medical History: No relevant medical history reported.

Family History: No relevant family history reported.

Past Dental History: First dental visit.

6
Personal History:

• Diet history: Mixed diet, 2 major (rice, pulses, vegetables) + 2 minor

(tea, snacks) meals/day.

• Oral hygiene: Brushes once daily with medium bristle toothbrush and
fluoridated toothpaste for 3-4 minutes in vertical/horizontal stroke
motion. Changes his toothbrush every 2-3 months. Occasional use of
tooth pick.
7
Personal History:
• Deleterious habit:
Betel quid: 2-3 per day since 2 years
Flavored areca nut (Rajnigandha): 1 sachet for about 1-2 days
since 2 years

8
General examination
• Vitals:
Peripheral Signs:
• Pulse: 74 beats/minute
Pallor
• Respiratory rate: 18 cycles/ minute, Icterus
abdominothoracic
Cyanosis
Absent
• Blood pressure: 110/ 70 mmHg in right arm
Clubbing
in supine position
Edema
• Temperature: Afebrile to touch
Dehydration 9
• Height: 5 feet 7 inch (as said by patient)
• Weight: 70 kg
• Body mass index: 24.20 kg/sq m
(Normal)

10
General Body Examination

• No abnormalities/swelling present in extremities

11
Extraoral examination:
No abnormality detected in:
Face
Skin
Hair
Eyes
Ears
Nose
Neck 12
 Temporomandibular Joint (TMJ)
• Inspection:
Bilateral pre-auricular area appeared symmetrical.
• Palpation:
• Extra-auricular: Bilateral well coordinated synchronous movement of
condyle felt. No tenderness present at rest, occlusion, right/left lateral
excursion, protrusion and mouth opening. No joint noise felt
• Intra-auricular: No tenderness present at rest, occlusion, right/left
lateral excursion, protrusion and inter-incisal opening.
• Auscultation: No joint noise heard.
• Range of motion: Interincisal opening: 15 mm, Right/left lateral
excursion: 8mm 13
• Protrusion: 7mm, No deflection/deviation present.
Muscles of Mastication

• Primary muscles of mastication: Bilateral temporalis and masseter

appeared symmetrical with adequate bulk of masseter on palpation.
Bilateral lateral and medial pterygoid are non-tender on functional and
non-functional manipulation.
• Accessory muscles of mastication: Bilateral digastric,
sternocleidomastoid and trapezius appeared clinically normal.

14
Lymph Node:
• Right submandibular node firm, round, mobile, approximately 1.5 cm,
non-tender on palpation

Cranial Nerve Examination:

• No abnormality detected in bilateral trigeminal and facial nerve
examination.
15
 Intraoral examination
• Halitosis: Not present
Soft tissue:
• Presence of blanching in right/left buccal mucosa, upper/lower labial mucosa,
hard/soft palate, floor of mouth .
• Anterior/posterior faucial pillars, bilateral tonsils and posterior pharyngeal walls
appeared clinically normal.
• No evidence of vesicle or ulceration is seen.
• Maxillary and mandibular labial frenum has mucogingival level of attachment.
• Bilateral parotid and submandibular gland salivary flow is clear, copious and
watery. 16
❖Bilateral right and left buccal mucosa, upper and lower labial
mucosa is inelastic on palpation.
❖Presence of fibrous bands in buccal mucosa and in retromolar
(pterygomandibular raphe region) on palpation.
❖Cheek flexibility: Right: 78mm, Left: 80mm
❖Dorsal and ventral surface, lateral border of tongue appears
normal.
❖Tongue Protrusion: 18mm

17
Right buccal mucosa Left buccal mucosa 18
Hard Palate
19
Gingiva:
• Color: Pink with melanotic pigmentation
• Contour: scalloping margin, knife edged marginal gingiva, triangular
shaped interdental papilla
• Consistency: firm
• Size: not enlarged
• Stippling: present
• Bleeding on probing: present wrt to lower anteriors
• Position: at the level of CEJ
• Periodontal pocket: absent
• Furcation involvement : absent
20
 Hard tissue

• Generalized plaque, stains and calculus deposits.

• Overjet: 2mm
• Overbite: 3mm

• Molar relation: Bilateral Angle’s Class I

• Canine relation: Bilateral class I

21
Case summary
• A 28 years male presented to the Department of Oral Medicine and Radiology
with chief complain of difficulty in opening mouth since 1 month.
• Patient noticed he could not fully open his mouth, while having food, which
was gradually progressive in nature.
• History of burning sensation (NRS: 6/10) since 1 month. It was insidious in
onset, gradually progressive, persistent throughout the day, aggravated with
hot and spicy foods, no relieving factors documented.
• History of difficulty in swallowing present since 1 month.
• History of occasional blister formation which ruptures leading to formation of
wound inside mouth.
• No other relevant history of presenting illness.
22
On local examination:
• Presence of blanching in right/left buccal mucosa, upper/lower labial
mucosa, hard/soft palate, floor of mouth .
❖Bilateral right and left buccal mucosa, upper and lower labial mucosa
inelastic on palpation.
❖Presence of fibrous bands in buccal mucosa and in retromolar
(pterygomandibular raphe region) on palpation.
❖Mouth opening: 15 mm
❖Cheek flexibility: Right: 78mm, Left: 80mm
❖Tongue protrusion: 18mm
23
 Provisional diagnosis
Oral Submucous Fibrosis (Grade 3)
• History
• Clinical examination

24
 Differential diagnosis: Oral Submucous Fibrosis
Disease Points for Points against
Oral Loss of flexibility of oral Fibrosis of skin, systemic
manifestation of mucosa, pale oral manifestation
scleroderma mucosa
Oral Limited mouth opening Multiple soft nodules on
manifestation of the mucosa,
amyloidosis Macroglossia, Systemic
manifestation, Age
Generalized Palpable fibrous bands Usually congenital,
fibromatosis in bilateral buccal multiple fibrous nodules in
mucosa other parts of the body 25
 Investigations
SN Parameters Values Reference range
1 Hemoglobin 12.3 gm/dL 11-16
2 TLC 8200 cells/mm cube 4000-11000
3 DLC N 52, L 38, M 06, E05 N 40-75, L 20-45, M 2-10, E 1-
6
4 Platelets 333000 cells/ mm cube 150000- 400000
5 Serology HIV, HBsAg, HCV (Negative)
6 Random Blood 100 mg/dL < 140
Sugar
26
SN Parameters Values Reference range

7 Bleeding time 3 minute 3-6 minute

8 Clotting time 7 minute 6-10 minute

9 Prothrombin time/INR 14 sec/1 14-16 sec

10 Activated partial 29 sec 26-45 sec

thromboplastin time

27
Biopsy October 21, 2018

28

4x 10x
Final Diagnosis

Oral Submucous Fibrosis Grade 3

29
 Treatment plan
Systemic phase:
• Not required
Initial phase:
• Oral prophylaxis and oral hygiene instructions (Dept. of Periodontology
and Oral Implantology)
Corrective phase:
• Intralesional injection of dexamethasone and hyaluronidase in bilateral
buccal mucosa, labial mucosa and soft palate. (Dept. of Oral Medicine and
Radiology)
Maintenance phase: Maintain good oral hygiene, periodic follow up and
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stoppage of deleterious habits.
Advice: Habit cessation

• Rx:
Cap. Adcumin 500mg X QID X 45 days.

Schedule of Intralesional Injection:

• Intralesional Dexamethasone(4mg/ml), 2ml twice a week for
first 2 weeks
• Intralesional Dexamethasone(4mg/ml), 2ml and Hyaluronidase
1500 IU twice a week for next 4 weeks
31
• Mouth Opening Exercise Device

32
Visit Burning Interincisal Tongue Cheek Elasticity
Sensation Distance protrusion Right Left
(NRS)
1st 6 NMO: 15mm 18mm 78mm 80mm
FMO: 16mm
2nd 4 NMO: 15mm 18mm 78mm 80mm
FMO: 17mm
3rd 2 NMO: 16mm 18mm 79mm 81mm
FMO: 17mm
4th 1 NMO: 16mm 19mm 79mm 81mm
FMO: 17mm
5th 1 NMO: 17mm 21mm 83mm 83mm
FMO: 19mm 33

6th 0 NMO: 19mm 21mm 83mm 83mm

FMO: 20 mm
Visit Burning Interincisal Tongue Cheek Elasticity
Sensation Distance protrusion
Right Left
7th 0 NMO: 19mm 23mm 78mm 80mm
FMO: 22mm
8th 0 NMO: 21 mm 23mm 78mm 80mm
FMO: 24 mm
9th 0 NMO: 21mm 23mm 79mm 81mm
FMO: 24mm
10th 0 NMO: 24mm 24mm 79mm 81mm
FMO: 26mm
11th 0 NMO: 24 mm 24mm 83mm 83mm
FMO: 26mm 34

12th 0 NMO: 24 mm 24mm 83mm 83mm

FMO: 26mm
 November 4, 2018 December 16, 2018

Before: 15mm After: 24mm

Date: February 10, 2019 Mouth opening: 24mm 35

Cheek elasticity: 83 mm, both sides
Tongue protrusion: 24mm
Discussion: Oral Submucous Fibrosis
Pindborg 1966
“an insidious chronic disease affecting any part of the oral cavity and
sometimes pharynx. Although occasionally preceded by and/or
associated with vesicle formation, it is always associated with juxta-
epithelial inflammatory reaction followed by fibroblastic changes in the
lamina propria, with epithelial atrophy leading to stiffness of the oral
mucosa causing trismus and difficulty in eating.”

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Pathogenesis

37
The Prodromal Symptoms (early OSF)
➢Burning sensation in the mouth when consuming spicy food,
➢Appearance of blisters especially on the palate,
➢Ulcerations or recurrent generalized inflammation of the oral
mucosa,
➢Defective gustatory sensation and dryness of' the mouth.

38
➢Petechiae are observed in about 22% of OSF cases, mostly on the
tongue followed by the labial and buccal mucosa with no sign of
blood dyscrasias or systemic disorders.
➢Pain in areas where submucosal fibrotic bands are developing
when palpated, is a useful clinical test.

39
The Advanced OSF
➢The oral mucosa becomes blanched and slightly opaque and white
fibrous bands appear.
➢The buccal mucosa and lips may be affected at an early stage
although it was thought that the palate and the faucial pillars are the
areas involved first.
➢The oral mucosa is involved symmetrically (with possible exception)
and the fibrous bands in the buccal mucosa run in a vertical
direction.
40
➢The density of the fibrous deposit varies from a slight whitish area
on the soft palate causing no symptoms to a dense fibrosis causing
fixation and shortening or even deviation of the uvula and soft
palate.
➢The fibrous tissue in the faucial pillars varies from a slight
submucosal accumulation in both pillars to a dense fibrosis
extending deep into the pillars with strangulation of the tonsils.
➢It is this dense fibrosis involving the tissue around the
pterygomandibular raphae that causes varying degrees of difficulty
in mouth opening. 41
 Grading of OSF (Kerr et al 2011):
• Grade 1 – Mild: Any features of the disease triad for OSF (burning, depapillation,
blanching or leathery mucosa) may be reported – and inter-incisal opening >35
mm
• Grade 2 – Moderate: Above features of OSF + inter-incisal limitation of opening
20–35 mm
• Grade 3 – Severe: Above features of OSF + inter-incisal opening <20 mm
• Grade 4A – OSF + other potentially malignant disorder on clinical examination
• Grade 4B – OSF with any grade of oral epithelial dysplasia on biopsy
• Grade 5 – OSF + oral squamous cell carcinoma (SCC)

42
Kerr AR, Warnakulasuriya S, Mighell AJ, Dietrich T, Nasser M, Rimal J, Jalil A, Bornstein MM, Nagao T, Fortune F,
Hazarey VH. A systematic review of medical interventions for oral submucous fibrosis and future research
opportunities. Oral diseases. 2011 Apr;17:42-57.
Differential Diagnosis
• Scleroderma
• Amyloidosis
• Generalized fibromatosis
• Iron deficiency anemia
• Temporomandibular disorder

43
Treatment Modalities

Anti-Inflammatory: Steroids
Immunomodulators
Pentoxifylline

Rajalalitha P, Vali S.
Anti-TGF-beta: Fresolimumab
Molecular
pathogenesis of
oral submucous
fibrosis–a collagen
metabolic disorder.
Journal of oral
pathology &
medicine. 2005
Cu-Chelators: D-penicillamine
Jul;34(6):321-8.
Anti-LOX:
D-penicillamine, Curcumin 44
Collagenase activator:
Colchicine
D-Penicillamine
• Copper chelator which blocks lysyl oxidase (LOX) activity
• Used in treatment of systemic sclerosis, pulmonary fibrosis, liver
fibrosis.
• Dose: 600mg
• Trade name: Cupriamine
• So far not used in treatment of OSF.

45
Pentoxyfylline:
• Methylxanthine derivative, with numerous biologic activities.
• Improves microcirculation and decreases aggregation of platelet as
well as granulocyte adhesion.
• Increases leukocyte deformability as well as inhibits neutrophil
adhesion and activation
• Causes degranulation of neutrophils, promotes natural killer cell
activity and inhibits T-cell and B-cell activation.

46
 Patil et al 2014
• A total of 106 subjects with clinico-pathologically diagnosed
OSMF
• Group A (pentoxifylline group): 400 mg pentoxifylline twice daily
• Group B (placebo group: multivitamins for 3 months)
• The patients in Group A showed significant improvement in all
the parameters measured, mouth opening, tongue protrusion,
pain associated with the condition, burning sensation and
difficulty in speech and swallowing.
• However, few patients from Group A complained of bloating,
47
nausea, anxiety and dyspepsia.
Patil S, Maheshwari S. Efficacy of pentoxifylline in the management of oral submucous fibrosis. Journal of Orofacial
Sciences. 2014 Jul 1;6(2):94.
Dexamethasone and Hyaluronidase in OSF
• Dexamethasone (4mg/ml, 2ml) is the widely used steroid because
of its ability to inhibit the production of inflammatory factors and
increased apoptosis of inflammatory cells
• Also inhibits the proliferation of fibroblasts while causing up -
regulation of collagenase synthesis and down-regulation of
collagen production.
• Provides greater relief from burning sensation associated with
OSF.

48
Dexamethasone and Hyaluronidase in OSF
• Hyaluronidase(1500IU) is often used as an adjunct to
dexamethasone treatment.
• Acts by breaking down hyaluronic acid thereby lowering the
viscosity of the intercellular cement substances and also decreases
collagen formation.

49
Aara et al 2012
• Study population: 40 male patients with OSF.
• 20 patients: Pentoxifylline group, 400 mg twice dailey for first 4weeks
and thrice daily for next 8 weeks
• 20 patients: Dexamethasone group, received biweekly intralesional
injections of Dexamethasone (4mg/ml), Hyaluronidase 1500 IU and
0.5 ml of Lignocaine 2% for a period of 12 weeks.
• Parameters taken in the study: burning sensation, mouth opening,
tongue protrusion and cheek flexibility.
50
Aara et al 2012
• Result: significant improvement in dexamethasone group compared
to pentoxifylline group. Nevertheless pentoxifylline group also
showed statistically significant improvement in all the parameters.

Aara A, Satishkumar GP, Vani C, Reddy V, Sreekanth K, Ibrahim M. Comparative study of intralesional
dexamethasone, hyaluronidase and oral pentoxifylline in patients with oral submucous fibrosis. Global Journal 51
of Medical Research. 2012 Aug 19;12(7).
Veedu RA 2015
• Total : Forty-five subjects , randomly divided into three groups
• Each group received biweekly submucosal injections of
hyaluronidase (1500 I.U), dexamethasone (8 mg) or a combination of
both (750 I.U and 4 mg), respectively for a period of 5 weeks.
• Improvement in pain upon opening, burning sensation and tightness
of mucosa as perceived by the patient, as well as improvement in
mouth opening measured clinically were

52
 Result:
• All drugs tested, alone and in combination, were effective in
alleviating measured symptoms.
• Hyaluronidase was effective in reducing the tightness of mucosa and
improving mouth opening.
• Dexamethasone provided greater relief from burning sensation
associated with OSF.
• Although, the combination of hyaluronidase and dexamethasone
provided the added effect of both the drugs, the improvement in
tightness of mucosa and mouth opening were less when compared to
hyaluronidase administered group
53
Veedu, R.A. and Balan, A., 2015. A randomized double-blind, multiple-arm trial comparing the efficacy of submucosal injections of
hyaluronidase, dexamethasone, and combination of dexamethasone and hyaluronidase in the management of oral submucous
fibrosis. Oral surgery, oral medicine, oral pathology and oral radiology, 120(5), pp.588-593.
Curcumin:
• Curcumin (diferuloylmethane) is a polyphenol compound isolated
from ground rhizomes of the plant (Curcuma longa)
• Reduces inflammation by lowering histamine levels and by possibly
increasing the production of natural cortisone by adrenal glands
• Attenuates inflammatory response of TNF-α stimulated human
endothelial cells by interfering with NFκB (nuclear factor kappa-light-
chain-enhancer of activated B cells).

54
Curcumin:
• Also capable of preventing platelet derived growth factor (PDGF).
• Scavenges superoxide radicals, hydrogen peroxide and nitric oxide
(NO) from activated macrophages, reducing iron complex and
inhibiting lipid peroxidation.
• Scavenges various reactive oxygen species produced by
macrophages (including superoxide anions, hydrogen peroxide and
nitrite radicals) both in vitro as well as in vivo.

55
 Hazarey et al. 2015
• Total subjects: 30 clinically diagnosed cases of OSF
• Test group: received Curcumin lozenges (2gm per day)
• Control group: received Clobetasol propionate, 0.05% ointment
• The test group showed 5.93 (±2.37) mm increase in mouth opening
compared to 2.66 (±1.76) mm of the control group.
• In relation to VAS scale:
– Test group: Average reduction 64
– Control group: Average reduction 34
56
Hazarey VK, Sakrikar AR, Ganvir SM. Efficacy of curcumin in the treatment for oral submucous fibrosis-A
randomized clinical trial. Journal of oral and maxillofacial pathology: JOMFP. 2015 May;19(2):145.
Q. What is the efficacy of curcumin compared to intralesional
dexamethasone in the treatment of oral submucous fibrosis?
Problem Intervention Comparison Outcome

Question Oral Curcumin Intralesional Efficacy

Submucous dexamethasone
Fibrosis

MeSH Oral Curcumin Dexamehtasone Efficacy

Submucous
Fibrosis
57
58
Comparison of curcumin with intralesional steroid
injections in Oral Submucous Fibrosis A randomized,
open-label interventional study
Total patients: 40
First group: treated with weekly intralesional injection of
4 mg Dexamethasone & 1500 I.U. Hyaluronidase
Second group: oral administration of two Curcumin tablets (Turmix
300 mg) per day for 3 months each.
Improvement of burning sensation, interincisal distance and tongue
protrusion was evaluated on a weekly basis. 59
 • Burning sensation improved in both the groups from early to late
stages.
• Complete resolution of burning sensation was noted with turmix.
• The mean increase in interincisal distance was 3.13 mm and
1.25 mm respectively in groups 1 &2.
• The interincisal distance improved in both the groups, with
significant results at the end of first month.
• Tongue protrusion showed greater recovery at the end of 1st month
in group 1 when compared with group 2.

60
Yadav M, Aravinda K, Saxena VS, Srinivas K, Ratnakar P, Gupta J, Sachdev AS, Shivhare P. Comparison of curcumin
with intralesional steroid injections in Oral Submucous Fibrosis–A randomized, open-label interventional study. Journal
of oral biology and craniofacial research. 2014 Sep 1;4(3):169-73.
Conclusion:
Till date, though several modalities have been tried, no
standardized treatment has been designed to treat OSF. Habit
cessation, intralesional corticosteroid and hyaluronidase and oral
curcumin as an anti-inflammatory and antioxidant agent can be
effective in treatment of OSF.

61
 References
➢ Glick M. Burket’s Oral Medicine. 12th edition. Connecticut: PMPH, 2015
➢ Neville B., Damm DD , Allen CM , Bouquot J and Neville BW. 2009. Oral And Maxillofacial Pathology, 3rd ed.
United Kingdom: Saunders Elsevier.
➢ Shafer WG, Hine MK, Levy BM, Rajendran R, Sivapathasundharam B. A textbook of oral pathology.
Philadelphia: Saunders; 1983 Sep 20.
➢ Kerr AR, Warnakulasuriya S, Mighell AJ, Dietrich T, Nasser M, Rimal J, Jalil A, Bornstein MM, Nagao T, Fortune
F, Hazarey VH. A systematic review of medical interventions for oral submucous fibrosis and future research
opportunities. Oral diseases. 2011 Apr 1;17(s1):42-57.
➢ Rimal J, Shrestha A. Validation of Nepalese Oral Health Impact Profile14 and Assessment of Its Impact in
Patients with Oral Submucous Fibrosis in Nepal. Journal of Nepal Health Research Council. 2015;13(29):43-9.
➢ Hazarey VK, Sakrikar AR, Ganvir SM. Efficacy of curcumin in the treatment for oral submucous fibrosis-A
randomized clinical trial. Journal of oral and maxillofacial pathology: JOMFP. 2015 May;19(2):145.
62
 References
➢ Veedu, R.A. and Balan, A., 2015. A randomized double-blind, multiple-arm trial comparing the efficacy of
submucosal injections of hyaluronidase, dexamethasone, and combination of dexamethasone and
hyaluronidase in the management of oral submucous fibrosis. Oral surgery, oral medicine, oral pathology and
oral radiology, 120(5), pp.588-593.
• Pindborg JJ. Oral submucous fibrosis: a review. Annals of the Academy of Medicine, Singapore. 1989
Sep;18(5):603-7.
• Rajendran R. Oral submucous fibrosis: etiology, pathogenesis, and future research. Bulletin of the World Health
Organization. 1994;72(6):985.
• Angadi PV, Rao SS. Areca nut in pathogenesis of oral submucous fibrosis: revisited. Oral and maxillofacial
surgery. 2011 Mar 1;15(1):1-9.
• Yadav M, Aravinda K, Saxena VS, Srinivas K, Ratnakar P, Gupta J, Sachdev AS, Shivhare P. Comparison of
curcumin with intralesional steroid injections in Oral Submucous Fibrosis–A randomized, open-label
interventional study. Journal of oral biology and craniofacial research. 2014 Sep 1;4(3):169-73.
63
• Rajalalitha P, Vali S. Molecular pathogenesis of oral submucous fibrosis–a collagen metabolic disorder. Journal
of oral pathology & medicine. 2005 Jul;34(6):321-8.
 References
• Patil S, Maheshwari S. Efficacy of pentoxifylline in the management of oral submucous fibrosis. Journal of
Orofacial Sciences. 2014 Jul 1;6(2):94.
• Aara A, Satishkumar GP, Vani C, Reddy V, Sreekanth K, Ibrahim M. Comparative study of intralesional
dexamethasone, hyaluronidase and oral pentoxifylline in patients with oral submucous fibrosis. Global Journal
of Medical Research. 2012 Aug 19;12(7).

64
Magnification in Microscope

• 4x : Red
• 10x : Yellow
• 40x : Black
• 100x : White

67
The VAS for Pain severity measurement

No Pain Worst Pain Possible

The VAS for Treatment Effect

No Pain Relief Complete Pain Relief

Numerical Rating Pain Scale
• The numerical rating scale offers the individual in pain to rate
their pain score.

• It is designed to be used by those over the age of 9.

• In the numerical scale, the user has the option to verbally rate
their scale from 0 to 10.

• 0 indicates the absence of pain, while 10 represents the most

intense pain possible.
 McGill Pain Questionnaire

• The McGill Pain Questionnaire consists of groupings of words that

describe pain. (Melzack, 1975)

• The person rating their pain ranks the words in each grouping. Some
examples of the words used are tugging, sharp and wretched.

• Once the person has rated their pain words, the administrator assigns
a numerical score, called the Pain Rating Index.
 McGill Pain Questionnaire

• Groups 1-10 = Somatic in nature

• Groups 11-15 = Affective
• Group 16 = Evaluative
• Group 17-20 = Miscellaneous words that are used in the scoring process.
73
 Pentoxifylline
• Methylated xanthine derivative
• Improves microcirculation and decreases aggregation of platelet as
well as granulocyte adhesion.
• Increases leukocyte deformability as well as inhibits neutrophil
adhesion and activation
• Causes degranulation of neutrophils, promotes natural killer cell
activity and inhibits T-cell and B-cell activation.
• Other xanthine derivatives: caffeine, theobromine, theophylline,
paraxanthine
 Limitations of D-penicillamine (DPA)
• D-penicillamine (DPA) leads to side effects in different ways:
collagen and elastin crosslinking are inhibited, which results in thin
and vulnerable skin and wound healing defects
• Toxic effects :
– thrombo- and leukocytopenia (incidence 5-15%),
– gastrointestinal disturbances (10-30%),
– changes or loss of taste (5-30%),
– loss of hair (1-2%), and
– partly proteinuria (5-20)
• Acute hypersensitive reactions include DPA-allergy (2-10%).
• Severe adverse effects are autoimmune phenomena such as
pemphigus, DPA-induced lupus erythematosus,
polymyositis/dermatomyositis, membranous glomerulopathy and
hypersensitivity pneumonitis and myasthenia (all less than 1%).
• The total incidence of side effects amounts to 30-60%, the withdrawal
rate is 20-30%
Types of Frenal Attachment

a. Mucosal
b. Mucogingival
c. Papillary
77
d. Papillary penetrating
Treatment modalities in OSF
Intralesional Injection/ Local Drug Delivery
• Dexamethasone (4mg/ml) as an anti-inflammatory agent
• Hyaluronidase 1500IU (break down intercellular substance)
• Placental extracts (Immunomodulator)
Peripheral Vasodilator
• Pentoxyfylline 400mg TID
Nutritional Supplement
• Vitamin A, B complex, Iron and other minerals 78
Physiotherapy:
• Forceful mouth opening exercise
• Kneading
• Heat therapy (Short wave/Long wave Diathermy)
Surgical Management:
• Submucosal resection of fibrotic bands and replacement
with a partial thickness skin or, mucosal graft
• Bilateral temporalis myotomy
• Bilateral Coronoidectomy 79