42 years old Asian man c/o progressive limitation of his mouth opening over the last few years.

The history reveals various chewing habits. The examination: band like contractures on both cheeks and pale stretched oral mucosa.

Deferential Diagnosis:

Amyloidosis Lichen Planus Scleroderm Actinomycosis (chronic infection) Temporomandibular joint bony ankylosis & fibrous ankylosis Juvenile rheumatoid arthritis progressive myositis ossificans Radiation fibrosis Squamous Cell Carcinoma Oral submucous fibrosis

Final diagnosis oral submucous fibrosis

This is a highly potent,irriversible and chronic pre-cancerous condition that
affects various portions of the oral cavity as well as the pharynx.

It causes progressive fibrosis of submucosal tissues and juxta-epithelial

inflammatory reactions.

This disease also leads to fibro-elastic changes in the lamina propria along with epithelial atrophy, which results in stiffness of the oral mucosa, it affects soft palate, buccal mucosa and tongue.
It may become impossible to open to the mouth due to the extreme stiffness of the jaw.

Etiology :
Exact etiology is unknown. The suggested factors are, 1. Chronic Irritation

Chilies Areca nut Tobacco Chewing

2. Deficiency disease. 3. Defective iron metabolism 4. Bacterial Infection 5. Immunological disorders

6. Genetic disorder.

staging
Group I: This is the earliest stage and is not associated with mouth opening

limitations. It refers to patients with an interincisal distance of greater than 35 mm. Group II: This refers to patients with an interincisal distance of 26-35 mm. Group III: These are moderately advanced cases. This stage refers to patients with an interincisal distance of 15-26 mm. Fibrotic bands are visible at the soft palate, buccal mucosa and pterygomandibular raphe are present. Group IVA: Trismus is severe, with an interincisal distance of less than 15 mm and extensive fibrosis of all the oral mucosa. Group IVB: Disease is most advanced, with premalignant and malignant changes throughout the mucosa.

Sign and symptoms:

Progressive inability to open the mouth Oral pain and a burning sensation Increased salivation Pain in the ear or loss of hearing Nasal intonation of voice Thinning and stiffening of the lips. Pigmentation of the oral mucosa. Impaired mouth movements - eating, whistling, blowing, sucking etc Dysphagia to solids

Treatment:
1. Stop the habit of chewing betel nut and tobacco 2. Minimiz e the consumption of spicy foods and chilies 3. Maintain a good oral hygiene. 4. Get the third molars extracted. 5. Round off the sharp edges of teeth. 6. Take Vitamin B Complex, Vitamin A and Vitamin C 7. Take iron supplements. 8. Practice muscle stretching exercise for the mouth

Medical treatment:
Steroids :
weekly submucosal intralesional injections or topical application of steroids dexamethasone, Triamcinolone

Injection or topical hyaluronidase with or without steroids. Intra-lesional interferon gamma. Sub mucosal injection of healthy human placental extracts.

Surgical Treatment

Simple excision of the fibrous bands: Split-thickness skin grafting following bilateral temporalis myotomy or
coronoidectomy:

Nasolabial flaps and lingual pedicle flaps Use of a KTP-532 laser release

Done By

Zaid AL-Azem Yasser AL-Kadri

ID# 200810052 ID# 200911229