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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 30  |  Issue : 3  |  Page : 247-252

Ultrasonographic evaluation of oral submucous fibrosis patients: A noninvasive diagnostic approach


1 Department of Oral Medicine and Radiology, Yogita Dental College and Hospital, Khed, Ratnagiri, Maharashtra, India
2 V S P M's Dental College and Research Centre, Nagpur, Maharashtra, India

Date of Submission12-Jun-2018
Date of Acceptance02-Jul-2018
Date of Web Publication18-Oct-2018

Correspondence Address:
Dr. Aditya Dupare
1102/b Ashirwad Nagar, Nagpur - 440 024, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jiaomr.jiaomr_102_18

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   Abstract 


Background: Oral submucous fibrosis (OSMF) is one of the most common premalignant conditions seen in the Indian population. It affects all parts of oral cavity including buccal and labial mucosa, tongue, and soft and hard palate. Ultrasonography is a noninvasive, nonionizing technique, readily available, cost effective, and better accepted by patients. In USG, OSMF shows alteration in submucosal thickness and vascularity overlying the bands leading to reduced peak systolic velocity (PSV). These changes cannot be assessed during clinical and histological examination. In advanced cases, OSMF can be diagnosed based on the typical clinical picture but to assess prognosis and to monitor the response to treatment; USG can be a better diagnostic tool of choice. Aim: To evaluate the submucosal thickness and PSV using USG in OSMF patients. Materials and Methods: In total, 40 OSMF patients were selected from departmental OPD divided into four groups (OSMF stages I, II, III, and IVA) equally. They were subjected to ultrasonographic evaluation for submucosal thickness and PSV of buccal and labial mucosa bilaterally. Results: On statistical analysis, the results were found highly significant (P-value < 0.05). There is significantly increase in the submucosal thickness and decrease in PSV among the OSMF stages I, II, III, and IVA, respectively. Conclusion: USG is found to be very effective tool for the diagnosis of OSMF as it is noninvasive modality which does not cause any discomfort to the patient and provides qualitative and quantitative information of the condition.

Keywords: Oral submucous fibrosis, peak systolic velocity, submucosal thickness, ultrasonography


How to cite this article:
Dupare A, Dhole A, Motwani M. Ultrasonographic evaluation of oral submucous fibrosis patients: A noninvasive diagnostic approach. J Indian Acad Oral Med Radiol 2018;30:247-52

How to cite this URL:
Dupare A, Dhole A, Motwani M. Ultrasonographic evaluation of oral submucous fibrosis patients: A noninvasive diagnostic approach. J Indian Acad Oral Med Radiol [serial online] 2018 [cited 2019 Jan 23];30:247-52. Available from: http://www.jiaomr.in/text.asp?2018/30/3/247/243643




   Introduction Top


Oral submucous fibrosis (OSMF) is one of the most common premalignant conditions seen in the Indian population. It affects all parts of oral cavity including buccal mucosa, labial mucosa, tongue, and soft and hard palate. The etiology of OSMF is multifactorial but areca nut and its product are considered to be the main causative agent. The condition is characterized by burning sensation, blanching, and stiffness of the oral mucosa causing reduction in mouth opening.[1] Chair side examination alone may be subjective and is insufficient to characterize the disease severity. Biopsy is a minor surgical procedure, does have its limitations like more time consuming, causes some discomfort to patients, and also tissue obtained from single site may not be representative of the true extent of the disease.[2]

Ultrasonographic imaging is safe, easily available, noninvasive, nonionizing, and economically acceptable real-time modality that can be used to image superficial head and neck structure. As it is noninvasive, it has better patient acceptance. Also, because of the wider area can be imaged, USG may a valuable tool to determine the extent and severity of the disease as well as to monitor the response to the treatment, thus it supplementing clinical as well as histological details.[3],[4],[5] The ultrasonographic evaluation of OSMF draws inspiration from its application in scleroderma, where USG have been used for diagnosis as well as evaluation of prognosis. OSMF is similar in many aspects to scleroderma, where continuous and uncontrolled fibrosis accompanies a chronic inflammatory reaction. Manjunath et al. reported that USG can delineate feeble fibrotic bands in clinically normal appearing buccal mucosa in OSMF patients. They also show decreased vascularity (reduced peak systolic velocity [PSV]) in the affected area. Thus, patients with poor vascularity in the affected area responded poorly to treatment and suggested need to alter treatment schedule.[4],[6],[7]

Diagnostic accuracy of USG is found to be useful in the diagnosis of various malignant tumours, periapical pathologies, temporomandibular joint disorders. As we searched there are very few studies have reported in literature with the use of USG in OSMF and to best of our knowledge, not a single study to show its diagnostic potential in OSMF.[8]

Considering the need for early detection of OSMF, we aimed to conduct a study to evaluate the role of USG in OSMF using USG parameters, that is, submucosal thickness and PSV bilaterally on buccal and labial mucosa and compared it to healthy individuals with or without habits.

Aim

The aim of this study is evaluate the submucosal thickness and PSV using USG in OSMF patients.


   Materials and Methods Top


This is a hospital-based cross-sectional observational study, which was initiated after getting approval from Institutional ethics committee (IEC) and was carried out in the Department of oral Diagnosis, Medicine, and Radiology, VSPM Dental College and Research Centre, Nagpur, and Department of Radiodiagnosis, NKPSIMS, Nagpur. In the study group, OSMF patients were included, whereas patients with previous history with the management of OSMF and coexisting lesion with OSMF were excluded from the study. Total 40 subjects were selected randomly from the departmental OPD and categorized into four groups of 10 subjects as Group I-OSMF Stage I, Group II-OSMF Stage II, Group III-OSMF Stage III, and Group IV-OSMF Stage IVA.

After obtaining informed consent from all the subjects, detailed clinical history was recorded and clinical examination was carried out in dental chair under proper illumination. Patients with OSMF were graded clinically as per classification system given by Khanna and Andrade 1995.[9] All the subjects were divided into four groups as per inclusion and exclusion criteria. All the subjects then underwent USG examination. The submucosal thickness was measured in B-Mode, whereas peripheral arterial flow was examined and PSV was measured in color Doppler (D-Mode) for both buccal and labial mucosa. The patient was made to lie supine on the examination table with the shoulders supported by a pillow and the operator seated on the right side. The coupling gel was applied on the buccal and labial surfaces extra orally. Subjects were instructed to place his/her index finger intraorally against the lining mucosa so as to delineate the empty spaces of the oral cavity during scan. Transcutaneous imaging of the right and left buccal mucosa (RBM and LBM) and upper and lower labial mucosa (ULM and LLM) was performed by a single trained general radiologist. For buccal mucosa, the transducer probe was placed at the level of occlusal line. For ULM and LLM, the transducer probe was placed in the region of philtrum and mentalis, respectively.

Submucosal thickness measurements in millimeter (mm) were taken at three points, that is, the anterior (D1), middle (D2), and posterior (D3) for buccal mucosa. Similarly, for labial mucosa, the measurements were taken at right (D1), middle (D2), and left (D3) points. The mean submucosal thickness of three points (D1, D2, and D3) was calculated for buccal and labial mucosa. [Figure 1] is showing USG images of submucosal thickness in centimeter of all the four groups. The USG settings were shifted to D-Mode to calculate peripheral arterial PSV of buccal and labial mucosa. It was calculated along the hypoechoic band of submucosa and was recorded at the highest point of waveform, which is represented as volume (V1) in centimeter/second. [Figure 2] is showing USG images of PSV in centimeter/second of all the four groups. The data were summarized in terms of statistical parameters like mean, standard deviation, and range. The buccal and labial submucosal thickness on either side was obtained and summarized in terms of mean and standard deviation according to groups. One-way analysis of variance (ANOVA) was performed to determine the significance of difference of means across groups.
Figure 1: Ultrasonography images of submucosal thickness in oral submucous fibrosis

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Figure 2: Ultrasonography images of peak systolic velocity in oral submucous fibrosis

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   Results Top


The mean thickness of RBM differed highly significantly across stages with P value <0.0001 using one-way ANOVA. The mean for stage IV was maximum, whereas that of stage I was minimum. The mean thickness of LBM differed highly significantly across stages with P value <0.0001 using one-way ANOVA. The mean for stage IV was maximum, whereas that of stage I was minimum. The mean thickness of ULM differed highly significantly across stages with P < 0.0001 using one-way ANOVA. The mean thickness for stage IV was maximum, whereas that of stage I was minimum. The mean thickness of LLM differed highly significantly across stages with P < 0.0001 using one-way ANOVA. The mean thickness for stage IV was maximum, whereas that of stage I was minimum [Table 1] and [Graph 1].
Table 1: Comparison of the average submucosal thickness across four different stages for right and left buccal mucosa and upper and lower side of labial mucosa

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The mean PSV for RBM differed highly significantly across stages with P value <0.0001 using one-way ANOVA. The mean for stage IV was minimum, whereas that of stage I was maximum. The mean PSV for LBM differed highly significantly across stages with P value <0.0001 using one-way ANOVA. The mean for stage IV was minimum, whereas that of stage I was maximum. The mean PSV for ULM differed highly significantly across stages with P value <0.0001 using one-way ANOVA. The mean PSV for LLM differed highly significantly across stages with P value <0.0001 using one-way ANOVA [Table 2] and [Graph 2].
Table 2: Comparison of peak systolic velocity across four stages for right and left buccal mucosa and upper and lower side of labial mucosa

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So, statistically final analysis results showed that the severity of OSMF advances, submucosal thickness increases [Graph 1], and PSV decreases [Graph 2] in both buccal and labial mucosa bilaterally.


   Discussion Top


OSMF is of special concern not only due to its crippling condition that it produces in the patient but as the entire mucosa acquires malignant potential. Prevalence of this condition is very high in the Indian population. In OSMF, once the fibrotic bands are palpable, the diagnosis become quite obvious on clinical examination itself; biopsy is done just for confirmation. But, for early diagnosis before blanching appear or the bands become properly palpable, the clinical examination may not be diagnostic as it is subjective in nature. Moreover, there are no known markers available for early diagnosis of OSMF. Also, the affected oral mucosa acquires potential to transform into malignancy but because of reduced mouth opening, clinical examination as well as biopsy is difficult and early diagnosis of malignancy is not possible.[10]

Devathambi and Aswath[9] who reported significant increase in submucosal thickness with the advancement of stage of OSMF, but when the different stages were compared, there was no statistical significant difference between stages II and III OSMF but significant correlation of stage II with stages IVA and stage III with stage IVA.

USG is a noninvasive, real-time, nonionizing, comfortable, less expensive technique, and suitable for visualization of changes in the superficial structures like buccal and labial mucosa. It can examine larger area in less time. Diagnostic potential of USG has been reported by Shetty et al.[11] and Sureshkannan et al.[12] in metastatic cervical lymph nodes, Tiwari et al.[13] in periapical pathologies, Shrinvas ket al.[14] in facial space infection, Gandhi et al.[15] in OSCC, and Kundu et al.[16] in TMJ disorders. Despite these advantages of USG, very few studies have been conducted on USG in OSMF patients. Thus, we performed a study with an aim to evaluate the role of USG in OSMF only.

Similar study results were reported by Kumar et al.[17] who found significant increase in submucosal thickness in OSMF cases compared with controls but failed to elucidate statistical significance across the stages and USG findings as there is heterogeneous distribution of number of cases across the stages. In this study, there was significant correlation among OSMF stages and USG findings and it may be attribute to homogenous distribution of numbers in all groups of OSMF.

In our study, the echogenicity pattern reported on USG in cases showed areas of irregular hyperechoic linear streaks due to increased fibrous deposits in the submucous layer, whereas the submucosa of control group appeared hypoechoic band, which is accordance with study conducted by Krithika et al.[6] and Thapasum et al.,[18] who ultrasonographically demonstrated the junction between the hypoechoic submucosal bands and the muscle layer.

Vascularity also plays significant role in the treatment prognosis of OSMF. Poor vascularity in the affected region may respond poorly and more than average vascularity may suggest malignant changes in this study, peripheral arterial PSV in the submucosal band was assessed in color Doppler spectral mode of buccal and labial mucosa. PSV was evaluated in the past in various inflammatory and neoplastic conditions. Li et al.[7] performed USG in cases of scleroderma and reported decreased blood flow and increased echogenicity with increased fibrosis, and Gandhi et al.[15] reported the increased mean PSV in patient with malignancy against healthy subjects. The increase in PSV in malignancy cases were because of the angiogenesis, which results in increased lesion vascularity. The mean PSV of RBM and LBM and ULM and LLM reduced significantly among OSMF groups.The comparison of mean arterial PSV across groups for both buccal and labial mucosa was highly significant except patients in OSMF stages III and IVA.

This reduced PSV from control to stage III OSMF showed clinical correlation with degree of fibrosis and severity of condition. This is similar to the only study in the literature by Manjunath et al.,[4] who performed intracavitary pre- and post-treatment ultrasonographic PSV evaluation in OSMF patient. They found that USG demonstrates fibrous bands and pattern of overall vascularity in the affected area. Vascularity of mucosa overlying the band was found to be decreased with reduced flow velocity, while in between the bands were normal. They found USG peripheral venous PSV value was helpful in monitoring treatment prognosis and altering treatment schedule if needed.


   Conclusion Top


OSMF is a chronic inflammatory premalignant condition in which the severity varies site to site and requires effective assessment, management, and periodic follow-ups. It can be used as adjuvant diagnostic method or established methods to clinical and histopathological evaluation. USG is a valuable, noninvasive, affordable, and zero radiation diagnostic tool, which is easily accepted by patients and less time consuming. So, USG can be a promising tool for diagnosis, for assessment of the severity and for evaluation of prognosis of OSMF.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

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    Figures

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