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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 32  |  Issue : 4  |  Page : 347-353

Detection of oral submucous fibrosis using ultrasonography in a Navi Mumbai population: An analytical cross sectional study


1 Department of Oral Medicine and Radiology, Dr. D. Y. Patil, School of Dentistry, Nerul, Navi – Mumbai, India
2 Department of Oral Medicine and Radiology, Dr. G. D. Pol Foundation's YMT Dental College and Hospital, Navi – Mumbai, India

Date of Submission21-Jul-2020
Date of Decision27-Oct-2020
Date of Acceptance29-Oct-2020
Date of Web Publication28-Dec-2020

Correspondence Address:
Dr. Priyanka Vijay Patil
Department of Oral Medicine and Radiology, Dr. D.Y. Patil School of Dentistry, Nerul, Navi - Mumbai
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jiaomr.jiaomr_151_20

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   Abstract 


Background: Ultrasonography (USG) has emerged as a real time imaging modality capable of assessing the thickness and depth of the affected oral mucosa in a potentially malignant condition like Oral Submucous Fibrosis. Aim: To test the efficiency of Ultrasonography as a diagnostic tool in Oral Submucous Fibrosis and correlate it with clinical staging. Settings and Design: Analytical Cross-sectional study conducted in Department of Oral Medicine, Diagnosis and Radiology (OMDR) for patients with a history of areca nut chewing, with and without Oral Submucous Fibrosis with USG for assessing Masseter thickness on right and left side. Materials and Methods: USG was done to assess Masseter muscle thickness on the right and left side for 90 patients, 45 with a history of habit and Oral Submucous Fibrosis and 45 with history of habit and without Oral Submucous Fibrosis. Statistical Analysis: Using SPSS Software, Intra, and Intergroup comparison of frequencies of clinical variables and thickness of masseter muscle on USG was done using the Chiquare test. Result: In group 1, intergroup comparisons showed a concomitant increase in Masseter thickness with an increase in severity of Oral Submucous Fibrosis on USG, which was statistically significant. In group 2, USG could detect the increased thickness of the masseter despite the absence of clinical signs and symptoms. Conclusion: Ultrasonography was effective in determining the thickness of the Masseter in subjects with Oral Submucous Fibrosis. Initial thickening of the muscle in patients with no Oral Submucous Fibrosis was noted, thus proving the diagnostic value of USG in Oral Submucous Fibrosis.

Keywords: Masseter muscle hypertrophy, oral submucous fibrosis, potentially malignant condition, Ultrasonography


How to cite this article:
Patil PV, Navalkar A. Detection of oral submucous fibrosis using ultrasonography in a Navi Mumbai population: An analytical cross sectional study. J Indian Acad Oral Med Radiol 2020;32:347-53

How to cite this URL:
Patil PV, Navalkar A. Detection of oral submucous fibrosis using ultrasonography in a Navi Mumbai population: An analytical cross sectional study. J Indian Acad Oral Med Radiol [serial online] 2020 [cited 2021 Jan 16];32:347-53. Available from: https://www.jiaomr.in/text.asp?2020/32/4/347/305267




   Introduction Top


Oral submucous fibrosis is a potentially malignant, irreversible condition affecting the oral cavity. WHO in 2005 has termed Oral Submucous Fibrosis as a Potentially Malignant Condition with a high rate of malignant transformation of 7 to 13%.[1],[2]

S.G. Joshi in 1953, described Oral submucous fibrosis as a disease, characterized by stomatitis, and vesiculation in its early stages followed by the stiffening of the oral mucosa with subsequent difficulty in opening the mouth.[3]

Ultrasonography (USG) is widely recognized as a non-invasive imaging modality for early detection of Oral submucous fibrosis by providing a qualitative and quantitative assessment of the affected tissue which can be correlated with the clinical staging.[4]


   Aims and Objectives Top


The aim of the study was to assess the efficiency of USG in Oral submucous fibrosis to delineate fibrotic bands in affected mucosa in advanced cases as well as clinically normal appearing mucosa and to correlate with clinical and functional examination.

Objectives of the study were to test the masseter muscle band thickness on the right and left side using diagnostic USG and prove the efficiency of ultrasound as a non-invasive diagnostic modality in Oral submucous fibrosis.


   Materials and Method Top


The study was conducted in the department of Oral Medicine and Radiology on 90 participants. Ninety total samples with and without Oral Submucous Fibrosis were recruited in 2 groups of 45 samples each as study and control groups, respectively.

Patients with a history of chewing areca nut and its commercial preparations, over 6 months duration, with and without clinical features of burning sensation, intolerance to hot and spicy food, inability to open the mouth, blanching, and clinically palpable fibrous bands were included in the study.

Patients who had received treatment for Oral Submucous Fibrosis, severely restricted mouth opening (<20 mm), restricted mouth opening because of any dental or any TMJ pathologies, and those who refused to fill the consent form were excluded from the study.

The Sample size of 87 was determined using the formula



Where Zα is the z variate of alpha error i.e., a constant with value 1.96, Zβ is the z variate of beta error i.e., a constant with value 0.84, P is the proportion of finding.

Ninety patients, 69 (76.66%) Males and 21 (23.33%) Females in the age group of 20-50 years reporting to the Outpatient department (OPD) were screened for the habit of chewing gutkha, areca nut, and any of its commercial preparations of 6 months duration or more. Patients with a positive history of habit were then examined for clinical signs and symptoms of Oral Submucous Fibrosis such as a burning sensation in the oral cavity, intolerance to hot and spicy food, blanching, clinically palpable fibrous bands, and inability to open the mouth [Figure 1]a, [Figure 1]b, [Figure 1]c, [Figure 1]d, [Figure 2]a, [Figure 2]b, [Figure 2]c and [Figure 3]a, [Figure 3]b, [Figure 3]c. Mouth opening was measured in millimeters using a Vernier Caliper. Clinical and Functional staging according to More et al. classification was given.[5]
Figure 1: (a) Right cheek showing line joining anterior buccal mucosa (ABM) and posterior buccal mucosa (PBM) points to place transducer. (b) Left cheek showing anterior buccal mucosa (ABM) and posterior buccal mucosa (PBM) points to place transducer. (c) Placement of the linear transducer on the right cheek. (d) Placement of the linear transducer on the left cheek

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Figure 2: (a) Clinical image showing blanching on right buccal mucosa. (b) Clinical image showing blanching on left buccal mucosa. (c) Measurement of interincisal mouth opening by Vernier Calliper. (d) Masseter muscle thickness seen on Ultrasonography scan of right buccal mucosa. (e) Masseter muscle thickness seen on Ultrasonography scan of left buccal mucosa

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Figure 3: (a) Group 2: Right Buccal mucosa showing absence of blanching. (b) Group 2: Left Buccal mucosa showing absence of blanching. (c) Measurement of interincisal mouth opening by Vernier Calliper. (d) Ultrasonography of Masseter muscle thickness on right side. (e) Ultrasonography of Masseter muscle thickness on left side

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USG procedure was performed in the reputed radiology clinic by a trained radiologist using Siemens Acuson S2000 USG Machine with scanning frequency 15-16 MHZ and high frequency linear array, transducer Probe (length 18 cm and width 6 Cm). Each procedure required 20 minutes to perform.

The patient was made to lay supine. Two points were marked on the right and left sides of the patient's face. The 1st point was 1 cm anterior to the anterior border of the masseter muscle showing the posterior buccal mucosa (PBM) and the 2nd one was 1 cm posterior to the commissure of the lip showing the anterior buccal mucosa (ABM) [Figure 1]a, [Figure 1]b, Ultrasonography gel applied to the transducer probe and they were instructed to show the mucosa by placing the tongue against the lining mucosa and blow out to delineate the empty space of the oral cavity. The probe was placed parallel to the lower border of the mandible [Figure 1]c, [Figure 1]d and the distance between the PBM and the ABM was recorded as a hyperechoic line which was identified as the masseter muscle [Figure 2]d, [Figure 2]e, and [Figure 3]d, [Figure 3]e. The thickness of the muscle was measured in millimeters (mm) using the USG software. Ethical approval was taken from the ethical cum research committee of the Yerala Medical Trust's Dental College and Hospital (YMTDCH) (under the vide letter no. YMTDC/IECOUT/2016-2017- 02 dated 10.09.2016) and a written informed consent form had been obtained from all the participants of the study. The study was conducted by following all the protocols and principles under the purview of Helsinki declaration (1975).

Statistical formula

Data were compiled on a Microsoft office Excel sheet and subjected to statistical analysis using SPSS Software. Intragroup and Intergroup comparison of frequencies of clinical variables and thickness of masseter muscle on USG was done using Chi-square test.


   Result Top


Distribution and comparison of age per groups

Forty five patients, both males and females with a positive history of habits and clinical signs and symptoms of Oral submucous fibrosis and 45 patients, both males, and females with a positive history of habits but no signs and symptoms of Oral submucous fibrosis were selected.

Based on the severity of signs and symptoms of the clinical presentation, the study group was further divided into 3 subgroups comprising 15 patients each. These were designated as Group 1A, 1B, and 1C, respectively. The mean age in group 1A was 41.07 ± 10.912, group 1B was 42.27 ± 8.430, group 1C was 45.27 ± 9.169 and group 2 was 41.56 ± 9.452. There was statistically no significant difference (p > 0.05) seen for intergroup comparison of age. This showed that age as a confounding factor could be ruled out. 69 males (76.66%) and 21 females (23.33%) with a positive history of chewing gutkha, areca nut, and any of its commercial preparations with and without clinical signs and symptoms took part in the study. There was a statistically highly significant difference seen (p < 0.01) for the duration of exposure of product in the oral cavity which varied from chewing for few minutes and spitting it out to placing it in a buccal vestibule for two hours or more [Table 1].
Table 1: The duration of exposure of product in the oral cavity

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Frequencies of variables in Group 1

Interincisal mouth opening Intragroup comparison was statistically significant (P < 0.01) for clinical variables as the severity of the Oral Submucous Fibrosis progressed in group 1. Group 1A showed the interincisal opening of over 35 mm, Group 1B showed between 25 and 35 mm, Group 1C showed between 15 and 25 mm, and Group 2 showed between 35 and 40 mm. Vesicle formation was seen in 11 patients in Group 1A, 3 patients in Group 1B, and 3 patients in Group 1C. Xerostomia was observed in 9 Patients in Group 1A, 13 patients in Group 1B, and 7 patients in Group 1C. Blanching of the oral mucosa was observed in all the patients in Group 1A, Group 1B, and Group 1C. Palpable fibrous bands were observed in 10 patients in group 1A, 15 patients in Group 1B and 15 patients in Group 1C. Group 1A did not exhibit a burning sensation and intolerance to hot and spicy food. 6 patients in Group 1B and 9 patients in Group 1C exhibited burning sensation and intolerance to hot and spicy food [Table 2].
Table 2: Comparison of Frequencies of various variables between Group 1 and Group 2

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The normal thickness of the Masseter muscle was in the range of 0.5-1 mm 0.5 and 1 mm, as reported in the literature.

Ultrasonography examination

Group 1A showed a mean thickness of 1.90 mm on the right side and 1.96 mm on the left side. Group 1B showed a mean thickness was 2.48 mm on the right side and 2.35 mm on the left side. Group 1C showed a mean thickness was 3.01 mm on the right side and 3.02 mm on the left side. Group 2 showed a mean thickness was 1.31 mm on the right side and 1.33 mm on the left side. The mean Masseter thickness in Group 1A was less than in Group 1B (p < 0.01) and Group 1C (p < 0.01) [Table 3]. Intragroup comparison of Masseter muscle thickness was statistically significant (p < 0.01) in group 1C on the right side and (p < 0.01) on the left side [Table 4].
Table 3: Correlation of frequency and duration of habit with Ultrasonography findings (USG)

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Table 4: Inter group comparison of masseter muscle thickness on the right and left side

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Proposed USG Staging of Oral Submucous Fibrosis

The thickness of the masseter muscle above the base value was considered being an indicator of the start of mucosal changes in Oral Submucous Fibrosis. Masseter muscle thickness between 1.1 and 1.9 mm was considered as Stage I (U1), between 2 and 2.9 mm was considered as Stage II (U2), between 3-3.9 mm was considered as Stage III (U3), and, over 4 mm was considered as Stage IV (U4) [Table 5].
Table 5: Proposed ultrasonography-based staging

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Proposed Clinical, Functional, and USG-Based Staging of Oral Submucous Fibrosis

In Group 1A, 5 patients showed S1M1U1 Staging and 10 patients showed S1M1U2 Staging. In group 1B, 12 patients showed S2M2U2 Staging and 3 patients showed S2M2U3 Staging. In Group 1C, 13 patients showed S3 M3 U3 Staging 1 patient showed S3M3U2 staging and 1 patient showed S3M3U4 Staging. In Group 2A, 6 patients were staged as S0M0U0 and 39 patients were staged as S0M0U1 in group 2B [Table 6].
Table 6: Clinical, Functional, and Ultrasonography-based staging of oral submucous fibrosis (OSF)

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   Discussion Top


In India, oral cancer is one of the leading cancers today. It is the sixth common cancer in the world with a high incidence and mortality rate. The major reason for India being high on the global map of oral cancer is mainly attributed to the prolonged use of adverse habits such as tobacco, betel nut, areca nut, etc., which have been in practice since ancient times. Oral Submucous Fibrosis is now globally accepted as a potentially malignant condition, with the highest rate of malignant transformation amongst all potentially malignant lesions and conditions. Owing to its high rate of malignant transformation and increased risk of cancer, WHO has aptly defined this as a potentially malignant condition.

The patient sample in this study was selected over a wide age range, 20–50 years. Since the habit may start young, it is important to identify and make the patient aware of the potential hazards of consumption of gutkha, areca nut, or any of its commercial preparations.

Ultrasonography (USG) is a non-invasive diagnostic tool commonly used for soft tissue pathology. It is an accurate method, convenient, easy, and inexpensive to apply. Ultrasonography is easy to use for the detection of soft tissue related diseases in the oral and maxillofacial region. In Oral submucous fibrosis, USG makes up a full representation of the cross-section of the buccal and labial mucosa in the submucosal and muscular planes. The mucosal lining appears as a hyperechoic line and the submucosa as a hypoechoic band supported by muscle planes.

Oral submucous fibrosis is characterized by progressive fibrosis of oral cavity, which begins posteriorly and then spreads to the anterior region. The masseter muscle was considered in this study for its posterior location and convenience to perform an ultrasound. Other muscles such as Buccinator and Circum oris were not considered because of inconvenience in performing the USG procedure.

Ultrasonography Examination of Group 1 revealed that the mean Masseter muscle thickness in Group 1A was less than that in Group 1B (p < 0.01) and that in Group 1C (p < 0.01). Group 1C showed the maximum thickness of the Masseter muscle (p < 0.01).

Our study showed a statistically significant difference in the masseter muscle thickness between Group 1A, 1B, and 1C. This difference showed that there was an increase in the severity of masseter muscle thickness as the lesion advances because of chronicity of chewing activity of the muscle and increased deposition of collagen. Group 2 showed a mean thickness of 1.31 mm on the right side and 1.33 mm on the left side. Out of 45 controls, 6 samples showed a mean masseter muscle thickness at the base value, and 39 samples showed a mean masseter muscle thickness above the base value on the right and left side. This was attributed to the fact that areca nut components such as arecoline, tannin, and other alkaloids stimulate fibroblasts and cause an accumulation of collagen within the mucosa. Mild changes beginning within the mucosa due to this collagen deposition can be detected on the USG. Yoithapprabhunath et al. studied the effect of areca nut and concurrent molecular changes resulting in Oral Submucous Fibrosis and concluded Oral Submucous Fibrosis was a collagen metabolic disorder resulting from exposure to areca nut and the severity of the condition will cause more molecular changes in the nucleic acid ratios, proteins, and glycogen synthesis.[6] Prabhu et al. studied the role of areca nut in Oral Submucous Fibrosis and concluded that areca nut enhances collagen production, strengthening the cross-linkages, and reduces their degradation.[7] Tiwari et al. conducted a study in Oral Submucous Fibrosis patients by measuring the submucosal thickness using USG in normal healthy individuals without and without a history of the habit of areca nut and its commercial preparations.[8] They concluded that duration of habit had a direct correlation with the interincisal mouth opening, as the duration of habit increased the interincisal mouth opening decreased. They also concluded that USG was a reliable technique for early detection and assessing the severity of Oral Submucous Fibrosis. Krithika et al. concluded that USG of the buccal mucosa was able to demonstrate increased submucosal echogenicity and reduced echo differentiation between submucosa and muscle layer, which could differentiate between various sub-mucosal layers.[9] Devathambi et al. studied the efficacy of ultrasonography as a non-invasive tool in accessing the severity of Oral Submucous Fibrosis and also studied the correlation of frequency and duration of habit with the severity of Oral Submucous Fibrosis.[10] They concluded that the increased frequency and the duration of the habit led to submucosal thickness of buccal and co-existing masseter muscle hypertrophy.

In the present study, USG was able to detect very early changes in the masseter muscle in patients with a positive history of habit but the absence of clinical signs and symptoms. Since the USG can image superficial surfaces up to a depth of 4–7 mm, it can efficiently detect submucosal changes and alert the physician of the underlying changes. This will prompt the clinician to inform the patient of the dangers of pursuing such adverse habits which can cause irreversible damage.[11]

Limitation and Future Prospects

The limitation of the study was that it was carried out in a selected subpopulation of Navi Mumbai. More studies are needed to test the correlation over a larger sample size across many subpopulations to establish the efficiency of USG as a non-invasive diagnostic tool and to use the proposed USG-based classification in the diagnosis of Oral Submucous Fibrosis.


   Conclusion Top


The present study was undertaken to highlight the role of USG to detect changes in the masseter's thickness because of chewing gutkha, areca nut, and its commercial preparations. The results obtained showed that the USG could detect an increase in the masseter muscle thickness when compared to the baseline normal in patients who had a positive history of habit with and without clinical signs and symptoms of Oral Submucous Fibrosis in a non-invasive manner. Hence, the use of USG as a real time non-invasive imaging modality should be incorporated in patients with a history of habit with and without clinical signs and symptoms to show the beginning of fibrotic changes as showed by the increase in muscle thickness and thus warn the patient about the potential hazard of practicing deleterious habits and improving their quality of life.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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Kant P, Sharda N, Desilva N. Oral submucous fibrosis: A review. J Healtalk 2012;04:15-7.  Back to cited text no. 2
    
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Chakarvarty A, Panat SR, Sangamesh NC, Aggarwal A, Jha PC. Evaluation of masseter muscle hypertrophy in oral submucous fibrosis patients -an ultrasonographic study. J Clin Diagn Res 2014;8:45-7.  Back to cited text no. 3
    
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Lavanya R, Chaitanya NC, Waghray S, Babu DB, Badam RK. Diagnostic and therapeutic ultrasound in dentistry. J Dent Orofacial Res2015;11:32-6.  Back to cited text no. 4
    
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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. 5
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Yoithapprabhunath TR, Maheswaran T, Dineshshankar J, Anusushanth A, Sindhuja P, Sitra G. Pathogenesis and therapeutic intervention of oral submucous fibrosis. J Pharm Bioallied Sci 2013;5:85-8.  Back to cited text no. 6
    
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Prabhu RV, Prabhu V, Chatra L, Shenai P, Suvarna N, Dandekeri S. Areca nut and its role in oral submucous fibrosis. J Clin Exp Dent 2014;6:569-75.  Back to cited text no. 7
    
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Krithika C, Ramanathan S, Koteeswaran D, Sridhar C, Satheesh J, Krishna and Shiva Shankar M P. Ultrasonographic evaluation of oral submucous fibrosis in habitual areca nut chewers. Dentomaxillofac Radiol 2013;42:1-8.  Back to cited text no. 9
    
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Devathambi JR, Aswath N. Ultrasonographic evaluation of oral submucous fibrosis and masseteric hypertrophy. J Clin Imaging Sci 2013;3:12.  Back to cited text no. 10
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    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

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