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Year : 2018  |  Volume : 14  |  Issue : 2  |  Page : 394-397

Sonographic imaging of fibrosis of oral mucosa and its correlation with clinical staging in oral submucous fibrosis

1 Department of Oral Medicine and Radiology, Kamineni Institute of Dental Sciences, Nalgonda, Telangana, India
2 Department of General Radiology, Kamineni Institute of Medical Sciences, Nalgonda, Telangana, India

Date of Web Publication8-Mar-2018

Correspondence Address:
Dr. Lakshmi Kavitha Nadendla
Department of Oral Medicine and Radiology, Kamineni Institute of Dental Sciences, Sreepuram, Narketpally, Nalgonda, Telangana
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0973-1482.183194

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 > Abstract 

Background and Objectives: To evaluate the efficacy of ultrasonography (USG) as a noninvasive tool in assessing the severity of oral submucous fibrosis (OSMF) by measuring the submucosal thickness and also to correlate the sonographic changes with clinical staging.
Materials and Methods: The submucosal thickness of the upper and lower labial mucosa, anterior and posterior portions of the right and left buccal mucosa were measured using ultrasound in 64 patients comprising of 32 OSMF patients and 32 controls. Among the controls, 16 were with a habit of chewing gutkha and 16 were without any habit history.
Results: In OSMF group, four patients were with Stage I, 13 were with Stage II, 11 were with Stage III, and four with Stage IV. Results were analyzed by one-way analysis of variance for the significance of difference among the groups in submucosal thickness. As the stages of OSMF advanced, there was an increase in submucosal thickness of the buccal mucosa in the study group when compared with controls (P< 0.005).
Conclusion: USG is an effective noninvasive zero radiation tool for assessing the progression of OSMF.

Keywords: Mouth neoplasms, oral submucous fibrosis, precancerous conditions, ultrasonography

How to cite this article:
Nadendla LK, Tatikonda VK, Bangi BB, Bhayya H, Devulapally RV, Pokala A. Sonographic imaging of fibrosis of oral mucosa and its correlation with clinical staging in oral submucous fibrosis. J Can Res Ther 2018;14:394-7

How to cite this URL:
Nadendla LK, Tatikonda VK, Bangi BB, Bhayya H, Devulapally RV, Pokala A. Sonographic imaging of fibrosis of oral mucosa and its correlation with clinical staging in oral submucous fibrosis. J Can Res Ther [serial online] 2018 [cited 2020 May 26];14:394-7. Available from: http://www.cancerjournal.net/text.asp?2018/14/2/394/183194

 > Introduction Top

Oral submucous fibrosis (OSMF) is a chronic insidious disease affecting the oral cavity and sometimes pharynx. Although occasionally preceded and/or associated with vesicle formation is always associated with juxta-epithelial inflammatory reaction followed by fibro-elastic changes in lamina propria with epithelial atrophy leading to stiffness of oral cavity leading to trismus and inability to eat.[1] The tissues most frequently affected by OSMF in the oral cavity are buccal mucosa and retromolar area, followed by the soft palate, palatal fauces, uvula, tongue, and labial mucosa.[2] Clinical diagnosis of OSMF is usually made based on several characteristic features of OSMF, including intolerance to spicy foods, blanching and stiffness of the oral mucosa, fibrous bands in the buccal or labial mucosa, and progressive inability to open the mouth [Figure 1].[3] The accuracy of clinical assessment has been questioned because of intra- or inter-observer variability and possibility of impalpable fibrous bands in very early cases.[4] For these reasons, there has been a growing interest in the development of noninvasive diagnostic procedures. In recent years, the development of ultrasonography (USG) has spread throughout different fields of medicine. It is an accurate, convenient, easy, and inexpensive method to apply. Despite extensive studies, there is no conclusive evidence of adverse biological effects of the use of USG energy at diagnostic power levels in literature till now.[5]
Figure 1: Clinical presentation of oral submucous fibrosis

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 > Materials and Methods Top

In this study, we included 32 patients with OSMF, 16 controls with no habit history, and 16 controls with habit history but no clinically evident fibrosis. All the included patients and controls were of the age group >15 years of both genders. Controls were selected in such a way that the body mass index, age, and sex matched with that of patients. Patients with any pernicious habits were excluded from the study. Institutional ethical clearance was obtained and informed consent was taken from all the participants of the study. Diagnosis of OSMF is established based on proper habit history of chewing tobacco or tobacco-related products and clinical findings. Clinical staging was established for these patients using clinical staging system given by Khanna and Andrade.[6]

Stage I

Very early cases, normal mouth opening, burning sensation, excessive salivation, acute ulceration, and recurrent stomatitis.

Stage II

Early cases, mouth opening: 26–35 mm (interincisal opening), soft palate, and faucial pillars are areas primarily affected, buccal mucosa appears mottled and marbled, with dense, pale, depigmented, and fibrosed areas alternating with pink normal mucosa, red erythematous patches, and widespread sheets of fibrosis.

Stage III

Moderately advanced cases, mouth opening: 15–25 mm (interincisal opening), trismus, and vertical fibrous bands can be palpated and are firmly attached to underlying tissue, patient unable to puff out the cheeks or whistle, soft palate-fibrous bands seen to radiate from the pterygomandibular raphe or anterior faucial pillar in a scar-like appearance, atrophy of vermillion border of the lips, unilateral posterior cheek involvement with only ipsilateral involvement of the faucial pillar and soft palate, and reduced mouth opening.

Stage IVa

Advanced cases, stiffness/inelasticity of the oral mucosa, trismus, mouth opening: 2–15 mm (interincisal opening), fauces thickened, shortened and firm on palpation, uvula seen to be involved as a shrunken, small and fibrous bud, tongue movement restricted, papillary atrophy (diffuse), lips-circular band felt around entire mouth, and intraoral examination is difficult.

Stage IVb

Advanced cases with premalignant and malignant changes, OSMF and leukoplakia, OSMF and squamous cell carcinoma.

USG examination was carried out on all the participants using SEIMENS ACUSON X300 machine with an extraoral transducer with the frequency range from 3 to 20 kHz, with dimensions of 3 cm × 1 cm and with an ability to measure till the depth of 30 cm. Measurements were taken in six different locations in the oral cavity in all the participants. The six different locations are upper lip (UL), lower lip (LL) [Figure 2], right anterior buccal mucosa (RABM), right posterior buccal mucosa (RPBM) [Figure 3], left anterior buccal mucosa (LABM), and left posterior buccal mucosa (LPBM) [Figure 4]. Clinical staging and USG measurement values were tabulated and correlated accordingly. Statistical analysis was done using
Figure 2: Ultrasonography picture of submucosal thickness in the upper and lower labial mucosa

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Figure 3: Ultrasonography picture of submucosal thickness in the right anterior and posterior buccal mucosa

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Figure 4: Ultrasonography picture of submucosal thickness in the left anterior and posterior buccal mucosa

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SPSS software 20 (IBM corporation, Amonk, Newyork, USA). Analysis of variance test was done to check for the significance of mean difference among the groups.

 > Results Top

The study group of 32 patients were identified as being in different stages of OSMF – Stage I (n = 4), Stage II (n = 13), Stage III (n = 11), and Stage IV (n = 4). All 32 patients had a burning sensation in the mouth and varying degrees of restricted mouth opening. On intraoral examination, maximum interincisal mouth opening ranged from 13 to 45 mm. Blanching and buccal fibrous bands were present in 26 patients in Stages II, III, and IV. The floor of the mouth was involved in ten Stage III and two Stage IV patients and soft palate, uvula, and faucial pillars in 11 Stage III patients and one Stage IV patients. Restricted movement of the soft palate was seen in 12 patients and restricted tongue movement in 12 patients. As the stage of OSMF advances, there was a significant decrease in the ability to open the mouth.

[Table 1] data represent a statistically significant difference among various stages of OSMF and controls USG readings of submucosal thickness in ULs and LLs, anterior and posterior parts of the right and left buccal mucosa. The range of the normal submucosal thickness in both controls with and without habits was between 0.35 and 0.82 mm. In the study group, the submucosal thickness was more in the PBM than in the ABM probably due to the increased tendency of the people to keep the tobacco or betel nut in the region of the buccal pouch.
Table 1: Mean values of various groups and significance of difference among the groups

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[Table 1] data represent the comparison in USG measurements of submucosal thickness between different stages of OSMF. There is a gradual increase in mean values of submucosal thickness in increasing order as in controls without habits, controls with habits, Stage I, Stage II, Stage IV and Stage III in ULs and LLs, anterior and posterior buccal mucosa on both the right and left sides. The mean values of Stage IV are lower than Stage III. The reason for this may be the premalignant lesions resulted in higher grading in Stage IV patients in spite of having minimal fibrosis compared to Stage III patients. This relationship of submucosal thickness at various locations and in various stages of OSMF and controls was better represented in [Graph 1] and [Graph 1].

[Table 2] showing the level of significance on comparison of various grades of OSMF and controls with one another as a cross tabulation in with the mucosal thickness in UL, LL, RABM, RPBM, LABM, and LPBM (P< 0.05 is considered statistically significant). It showed a high statistical significance in the difference between cases of OSMF and controls.
Table 2: Multiple comparisons in submucosal thickness in various grades of oral submucous fibrosis at various locations using analysis of variance post hoc analysis

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 > Discussion Top

USG is based on the principle of inverse piezoelectric effect.[7] USG is a valuable diagnostic tool in various aspects of medicine such as liver diseases, renal diseases, prostate malignancies, salivary gland diseases, and pregnancy.[8] The stage of liver fibrosis shows important prognostic information as it is closely related to the risk for development of liver cirrhosis.[9] Recently, noninvasive procedures such as normal USG, modified high-frequency USG, and fibro scan are routinely used for the assessment of liver fibrosis.[10] In dentistry, the use of USG was studied in dental scanning, caries detection, dental fractures and cracks, soft tissue lesions, periapical lesions, maxillofacial fractures, periodontal bony defects, gingival thickness, muscle thickness, temporomandibular disorders, and implant dentistry.[11] Li et al.[12] used USG and detected several abnormalities in active lesions of localized scleroderma including decreased blood flow, increased echogenicity, loss of subcutaneous fat, and reduction in lesion size during treatment. Hesselstrand et al.[13] used high-frequency USG for assessment of systemic sclerosis. This intended us to evaluate OSMF using USG as a diagnostic tool.

In two similar studies by Müller et al.,[14],[15] thickness of gingiva and masticatory mucosa were measured using an intraoral ultrasonic transducer and concluded that the USG may be an elegant means to obtain valid information of mucosal thickness for varying purposes atraumatically, rapidly and with relatively low cost. Kamala et al.[16] in a study, used USG in diagnosing massetric hypertrophy in OSMF patients and concluded that there lies an association of massetric hypertrophy with OSMF. Manjunath et al.[17] evaluated OSMF in thirty patients using USG and concluded that USG provides a more accurate evaluation of fibrous bands and vascularity in OSMF cases. Devathambi and Aswath[18] in a study, used USG to assess OSMF and massetric hypertrophy in thirty OSMF patients, thirty controls and concluded USG as an effective noninvasive zero radiation tool for assessing the progression of OSMF. But in our study, we evaluated the submucosal thickness in six different locations in each patient and studied for correlation between clinical grading and submucosal thickness in USG. We found a high correlation between increase in submucosal thickness with the stage of the disease.

 > Conclusion Top

USG is a noninvasive, cheap procedure with high patient's acceptability. The present study only looked into only the submucosal region, which is replaced by fibrosis in this disease. However, OSMF also involves muscles and which may also be a reason for trismus. In this study, we have used extra oral transducers. Intraoral transducers might yield more accurate and more reliable results. In this study, only clinical grading was compared with USG. But in future studies, the correlation among clinical grading, histological grading, and USG may be evaluated. Hence, further more studies are required, addressing these factors to reach clearer conclusions.

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Conflicts of interest

There are no conflicts of interest.

 > References Top

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Shivakumar GC, Sahana S. Clinical staging of oral submucous fibrosis: A review. Int J Oral Med Sci 2011;10:2169.  Back to cited text no. 2
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Haider SM, Merchant AT, Fikree FF, Rahbar MH. Clinical and functional staging of oral submucous fibrosis. Br J Oral Maxillofac Surg 2000;38:12-5.  Back to cited text no. 4
Bakke M, Tuxen A, Vilmann P, Jensen BR, Vilmann A, Toft M. Ultrasound image of human masseter muscle related to bite force, electromyography, facial morphology, and occlusal factors. Scand J Dent Res 1992;100:164-71.  Back to cited text no. 5
Khanna JN, Andrade NN. Oral submucous fibrosis: A new concept in surgical management. Report of 100 cases. Int J Oral Maxillofac Surg 1995;24:433-9.  Back to cited text no. 6
Palmer PE. Manual of Diagnostic Ultrasound. New Millennium Edition. Geneva: WHO Publications; 2006. p. 3-16.  Back to cited text no. 7
Rubenstein WA, Gray G, Auh YH, Honig CL, Thorbjarnarson B, Williams JJ, et al. CT of fibrous tissues and tumors with sonographic correlation. AJR Am J Roentgenol 1986;147:1067-74.  Back to cited text no. 8
Stauber RE, Lackner C. Noninvasive diagnosis of hepatic fibrosis in chronic hepatitis C. World J Gastroenterol 2007;13:4287-94.  Back to cited text no. 9
Marín-Gabriel JC, Solís-Herruzo JA. Noninvasive assessment of liver fibrosis. Serum markers and transient elastography (FibroScan). Rev Esp Enferm Dig 2009;101:787-99.  Back to cited text no. 10
Marotti J, Heger S, Tinschert J, Tortamano P, Chuembou F, Radermacher K, et al. Recent advances of ultrasound imaging in dentistry – A review of the literature. Oral Surg Oral Med Oral Pathol Oral Radiol 2013;115:819-32.  Back to cited text no. 11
Li SC, Liebling MS, Haines KA. Ultrasonography is a sensitive tool for monitoring localized scleroderma. Rheumatology (Oxford) 2007;46:1316-9.  Back to cited text no. 12
Hesselstrand R, Scheja A, Wildt M, Akesson A. High-frequency ultrasound of skin involvement in systemic sclerosis reflects oedema, extension and severity in early disease. Rheumatology (Oxford) 2008;47:84-7.  Back to cited text no. 13
Eger T, Müller HP, Heinecke A. Ultrasonic determination of gingival thickness. Subject variation and influence of tooth type and clinical features. J Clin Periodontol 1996;23:839-45.  Back to cited text no. 14
Müller HP, Schaller N, Eger T, Heinecke A. Thickness of masticatory mucosa. J Clin Periodontol 2000;27:431-6.  Back to cited text no. 15
Kamala KA, Annigeri RG, Ashok L. Ultrasonic diagnosis of masseteric hypertrophy in oral submucous fibrosis: A preliminary study. J Indian Acad Oral Med Radiol 2010;22:197-200.  Back to cited text no. 16
  [Full text]  
Manjunath K, Rajaram PC, Saraswathi TR, Sivapathasundharam B, Sabarinath B, Koteeswaran D, et al. Evaluation of oral submucous fibrosis using ultrasonographic technique: A new diagnostic tool. Indian J Dent Res 2011;22:530-6.  Back to cited text no. 17
[PUBMED]  [Full text]  
Devathambi JR, Aswath N. Ultrasonographic evaluation of oral submucous fibrosis and masseteric hypertrophy. J Clin Imaging Sci 2013;3 Suppl 1:12.  Back to cited text no. 18


  [Figure 1], [Figure 2], [Figure 3], [Figure 4]

  [Table 1], [Table 2]


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