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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 34  |  Issue : 4  |  Page : 400-404

Comparison of oral submucosal thickness in oral submucous fibrosis patients before and after treatment using ultrasonography – A hospital-based study


1 Department of Oral Medicine and Radiology, Educare Institute of Dental Sciences, Kerala, India
2 Department of Oral Medicine and Radiology, Viswanath Katti Institute of Dental Sciences, KAHER, Belagavi, Karnataka, India
3 Department of Radiodiagnosis, Jawaharlal Nehru Medical College, KAHER, Belgavi, Karnataka, India

Date of Submission30-Jul-2022
Date of Decision22-Nov-2022
Date of Acceptance23-Nov-2022
Date of Web Publication09-Dec-2022

Correspondence Address:
Manjima Sasidharan
Associate Professor, Department of Oral Medicine and Radiology, Educare Institute of Dental Sciences, Malappuram, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jiaomr.jiaomr_218_22

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   Abstract 


Background: Oral submucous fibrosis (OMFS) is a chronic progressive, potentially malignant disorder of the oral cavity. The diagnosis is usually based on clinical findings, and normally, biopsy is not performed as it can result in scarring and worsening of the condition. The prognosis of the treatment is judged by clinical assessment, and it can vary among clinicians. Ultrasonography is a non-invasive technique used in diagnostic imaging for many decades, including oral and maxillofacial pathologies. Aim and Objective: The present study aimed to compare the oral submucosal thickness in OSMF patients before and after treatment using ultrasonography. Materials and Methods: Fifty OSMF patients were selected and recalled biweekly for two months for injecting dexamethasone and hyaluronidase intralesional injections. Each patient was subjected to ultrasonographic evaluation of oral mucosa before and at the end of treatment. Pre- and post-treatment ultrasonographic thickness of oral submucosa was compared using paired t-test. Result: The inference of the present study showed a reduction in the thickness of oral submucosa after treatment in OSMF. The decrease in thickness of the submucosa was statistically significant (p-value < 0.00), and also, there was a correlation between mouth opening and ultrasonographic measurements of the submucosa. Conclusion: Hence, ultrasonography can be used as a non-invasive tool for evaluating OSMF by comparing the change in the thickness of submucosa before and after treatment.

Keywords: Investigation, oral submucous fibrosis, submucosa, thickness, ultrasonography


How to cite this article:
Sasidharan M, Keluskar VK, Bagewadi AS, Patil SD. Comparison of oral submucosal thickness in oral submucous fibrosis patients before and after treatment using ultrasonography – A hospital-based study. J Indian Acad Oral Med Radiol 2022;34:400-4

How to cite this URL:
Sasidharan M, Keluskar VK, Bagewadi AS, Patil SD. Comparison of oral submucosal thickness in oral submucous fibrosis patients before and after treatment using ultrasonography – A hospital-based study. J Indian Acad Oral Med Radiol [serial online] 2022 [cited 2023 Feb 3];34:400-4. Available from: http://www.jiaomr.in/text.asp?2022/34/4/400/363027




   Introduction Top


Since prehistoric times, tobacco and betel nut-chewing habits have been rooted in human tradition. These habits have been the focus concerning the causation of premalignant lesions and conditions.[1] Oral submucous fibrosis is a potentially malignant disorder affecting the oral mucosa, resulting in stiffening, burning sensation and reduced mouth opening.[2],[3]

However, histopathology is the most commonly used method to diagnose OSMF; a biopsy is not performed in all patients as it results in scarring and more fibrosis.[4] The prognosis of the treatment is judged by clinical assessment, and it can vary among clinicians. Research is continuing for a non-invasive technique to aid in evaluating this disease.

Ultrasonography (USG) is a non-invasive imaging technique with a promising future as a diagnostic imaging tool in all specialities, especially dentistry.[5] It evaluates the lesion's dimensions and its relationship to the neighboring tissues. Some studies have shown that ultrasonography can be used as a non-invasive imaging modality to assess the extent and severity of fibrosis and vascularity across the mucous membrane.[6],[7] This study assessed the submucosal thickness of oral mucosa in OSMF patients using USG. The present study used ultrasonography to compare the pre- and post-treatment thickness of oral submucosa in patients with OSMF.


   Subjects and Methods Top


Fifty clinically diagnosed cases of OSMF of either sex in the 18–50 years were selected for the study. The sample size was calculated using the formula mentioned below:



Zα = 1.96 at 5% type 1 error

m = 1 number of control subjects per experimental subject

Zβ = 0.84 power or type 2 error

P1 = 0.38 probability of an event in Group 1

P2 = 0.20 probability of an event in Group 2

P* = P2 + mP1/m + 1

n = 50

Informed consent was taken from all the participants. The study participants were selected from the outpatient department and approved by the Research and Ethical Committee of KLE university's VK Institute of Dental College. (711/10/2012).

Inclusion criteria

  1. Fifty clinically diagnosed cases of OSMF.
  2. OSMF patients with restricted mouth opening between 20 and 35 mm.


Exclusion criteria

  1. Patients with severely restricted mouth opening (<20 mm), immobility of the tongue, and ulcerations on the oral mucosa.
  2. Pregnant patients.
  3. Patients who are allergic to the drugs prescribed during this study.
  4. Patients on medication or who had already undergone treatment for OSMF.
  5. Those who did not comply with the treatment were considered dropouts and excluded from the study.


Detailed case history and clinical examination were made for each patient. All patients with a positive history of chewing gutka, areca nut, pan masala, or other commercial products were advised to quit the habit completely. Ultrasonographic examination of buccal and labial mucosa was carried out before and after the treatment. The treatment schedule included intralesional injections of dexamethasone 4 mg/ml and hyaluronidase 1500 IU twice a week for 8 weeks. During every visit, intralesional injections were given on multiple sites of buccal and labial mucosa where fibrosis is felt. Topical triamcinolone acetonide (0.1%) was given to those patients with a symptomatic burning sensation. All patients were advised to perform oral physiotherapy exercises. Ultrasonography was done during the first appointment and after 8 weeks of treatment. Interincisal distance of all the patients was recorded before and after the treatment, i.e., on day 0 and after 8 weeks.

Ultrasonographic evaluation

Transcutaneous imaging was performed by a single-trained radiologist with patients in the supine position. Philips HD 11 ultrasonographic unit with a linear transducer with a frequency ranging from 5 to 12 MHz was used in the study. Before imaging, ultrasound gel was applied, and the participants were instructed to puff the cheek to delineate the oral cavity's space. For standardization of transcutaneous imaging of buccal mucosa, an imaginary line was drawn between two points. The first point was 1 cm anterior to the anterior border of the masseter muscle, indicating the posterior buccal mucosa, and the second was 1 cm posterior to the commissure of the lip, indicating anterior buccal mucosa [Figure 1]. Submucosal thickness was measured along this line on both the right and left sides [Figure 2]. For imaging the upper labial mucosa and lower labial mucosa, the transducer probe was placed in the mid-region of the upper and lower lip (philtrum and mentalis region). The mucosal lining was seen as a hyperechoic line, and the submucosa was a hypoechoic band supported by muscle planes. This band of hypoechogenicity between the hyperechoic mucosa and muscle layer was measured as submucosa [Figure 3] and [Figure 4].
Figure 1: Imaginary line for standardization of transcutaneous imaging of buccal mucosa

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Figure 2: Ultrasonographic scanning of buccal mucosa

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Figure 3: Pre-treatment ultrasonographic images of buccal mucosa

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Figure 4: Post-treatment ultrasonographic images of buccal mucosa

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Statistical analysis

Statistical Package for Social Sciences [SPSS] for Windows Version 22.0 Released 2013. Armonk, NY: IBM Corp., was used to perform statistical analysis. The statistically significant difference between the thickness of oral submucosa before and after the treatment was calculated using paired t-test. We used Karl Pearson's correlation test to compare pre- and post-treatment ultrasonographic thickness of submucosa with pre- and post-treatment mouth opening. The level of significance was set at P < 0.05.


   Results Top


The present study included 50 subjects in the age range of 18–55 yrs. Out of 50, 47 were males and 3 were females. Pre- and post-treatment thickness of oral submucosa over four sites were assessed by ultrasonography and compared using paired t-test [Table 1].
Table 1: Comparison of the pre-and post-treatment thickness of oral submucosa

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Mouth opening before and after treatment was compared using paired t-test [Table 2].
Table 2: Comparison of pre- and post-treatment mouth opening

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Pre-treatment mouth opening was correlated with the pre-treatment submucosal thickness of the right and left buccal mucosa and upper and lower labial mucosa. A statistically significant correlation was found between these two parameters [Table 3].
Table 3: Correlation of pre-treatment mouth opening with pre-treatment oral submucosal thickness

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Similarly, Post-treatment mouth opening was correlated with the post-treatment submucosal thickness of the right and left buccal mucosa and upper and lower labial mucosa. These values were also found to have a statistically significant correlation [Table 4].
Table 4: Correlation of post-treatment mouth opening with post-treatment oral submucosal thickness

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   Discussion Top


OSMF is a potentially malignant condition that is of multifactorial etiology.[8] This condition has a significant mortality rate because it can transform into oral cancer, particularly squamous cell carcinoma, as seen in 7.6% of the cases.[1] Ultrasonography is a real-time imaging system that transforms sound into visible light waves. The most important parameters describing the interactions between ultrasound and tissue through which it is transmitted are attenuation, velocity, and impedance.[9] The attenuation and velocity are directly proportional to the amount of collagen in the tissue and inversely proportional to the water content.[10],[11] Echogenicity is the ability to bounce an echo. Tissues with higher echogenicity are called “hyperechogenic” and are typically represented with lighter colors on images in ultrasonography. In contrast, tissues with lower echogenicity are called “hypoechogenic” and are represented with darker shades. Collagen has a greater modulus of elasticity than other tissue, which results in higher velocity and impedance and ultimately leads to more echogenicity.[12]

Recently, ultrasonography was used as a non-invasive investigative tool for evaluating OSMF. Evaluation of OSMF using ultrasonography demonstrates the fibrotic bands' number, length, and thickness. Considering this, the present study compared pre- and post-treatment submucosal thickness in patients with OSMF using ultrasonography. In this study, most patients were males (47) compared to females (3). The age range of the patients was 18–55 years with a mean age of 33.7 years.

In the past, studies have been conducted to compare submucosal thickness in OSMF patients and controls. A previous study assessed the vascularity of buccal mucosa before and after the treatment in OSMF.[6] Though USG has not been used to evaluate fibrosis of oral mucosa, it has been regularly used as a diagnostic tool in other fields like fibrosis of other organs, particularly the liver.[13] In the present study, the mean pretreatment submucosal thickness of right and left buccal mucosa was 0.168 cm and 0.164 cm. This thickness got reduced to 0.133 cm after the treatment. Likewise, the mean submucosal thickness of the upper and lower labial submucosa also decreased from 0.210 cm to 0.170 cm after eight weeks of treatment. All the results were statistically significant (p-value < 0.00). Due to the paucity of studies, the present study cannot be compared with previous studies.

In our study, the submucosa appeared as a hypoechoic band which was consistent with the ultrasonographic study done by Rangaiah et al.[14] who compared oral submucosal thickness in patients with OSMF and the control group. His observation revealed an increased thickness of the submucosa in OSMF compared to the control group. Another study was carried out by Devathambi JR, who assessed buccal mucosa thickness using ultrasonography in different stages of OSMF. The anterior buccal mucosa measurement in stage III OSMF patients (Khanna and Andrade classification) was 0.169 cm which is consistent with our study.[15]

The most effective non-surgical treatment for OSMF is the intralesional injection of a combination of corticosteroids and a hydrolyzing agent. Dexamethasone is a potent steroid that reduces the inflammation of the juxta-epithelial surface. Hyaluronidase is an enzyme that hydrolyzes the hyaluronic acid component or intracellular cement substances. It temporarily decreases the viscosity of the intercellular substances and promotes the diffusion of injected fluids, thus facilitating their action.[16]

James et al.[16] tried dexamethasone 1.5 ml, hyaluronidase 1500 IU with 0.5 ml lignocaine HCL intralesional biweekly for 4 weeks and found an improvement in the patient's mouth opening with a net gain of 6 ± 2 mm. The mean mouth opening was found to be improved by 11.47 mm by Panigrahi et al.[17] when used a combination of 1 ml triamcinolone acetonide (10 mg/ml) and hyaluronidase (1500) injection at 14 days' interval for eight weeks.

In our study, the mean pre-treatment mouth opening was 29.92 mm. After the treatment, the mean mouth opening increased to 34.98 mm, which was statistically significant (p-value < 0.00). The mean increase in the mouth opening was 5.06 mm. Better results in the present study could be attributed to adjunctive physiotherapy advised to the patient. Increased mouth opening seen in the study done by Panigrahi et al.[17] could be because of the local potency of triamcinolone acetonide injection.

In the present study, submucosal thickness decreased over four sites after the treatment, and there was a significant correlation between pre- and post-treatment mouth opening and submucosal thickness. Hence, it proves that mouth opening depends on the fibrosis of the submucosal layer. This is in accordance with the study by Shivakumar et al.[18] where mouth opening was correlated with fibrosis histopathologically. In contrast, in our study, mouth opening was correlated with ultrasonographic measurements of the submucosa. The literature does not reveal any other study which assessed the submucosal thickness before and after treatment in OSMF patients. Hence, the present study is the first of its kind where USG is used as an evaluation and prognostic tool in the treatment of OSMF by assessing the change in thickness of submucosa.

Even then, the most important drawback of ultrasound compared with histopathology is the failure to detect mild fibrosis and microscopic changes in the tissues.[18] This technique is operator sensitive as ultrasound scanning reading depends on the operator's experience.

Limitation

The muscle layer under the submucosa was not assessed as fibrosis in OSMF can involve muscle fibers and cause reduced mouth opening. This study did not assess the anterior and posterior buccal mucosa separately.

Future perspective

Future studies should be done to assess the thickness of the submucosa and the muscle layer in OSMF patients. Further studies can be undertaken to correlate submucosal thickness with chewing habits, clinical staging, and histological staging. Evaluation of OSMF using an intraoral probe may yield more accurate and reliable results.


   Conclusion Top


USG can be a non-invasive diagnostic tool for evaluating OSMF, especially for monitoring the treatment and assessing the prognosis. However, further studies are required in a larger population to substantiate the results and explore the scope of imaging in OSMF.

Key messages

Oral submucous fibrosis is a premalignant condition that is paradoxical for dentists who diagnose and treat the pathology. Medical and dental fields should work together and formulate innovative techniques to evaluate and investigate the prognosis of OSMF.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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Rao NR, Villa A, More CB, Jayasinghe RD, Kerr AR, Johnson NW. Oral submucous fibrosis: A recent narrative review with a proposed inter-professional approach for an early diagnosis and clinical management. J Otolaryngol Head Neck Surg 2020;49:1-11.  Back to cited text no. 1
    
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Manjunath K, Rajaram PC, Saraswathi TR, Sivapathasundharam B, Sabarinath B, Koteeswaran D, et al. Evaluation of oral submucous fibrosis using the ultrasonographic technique: A new diagnostic tool. Indian J Dent Res 2011;22:530-6.  Back to cited text no. 6
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Chandrasekharan K, Ramanathan S, Koteeswaran D, Chitathoor S, Satheesh Krishna J, Shiva Shankar MP. Ultrasonographic evaluation of oral submucous fibrosis in habitual areca nut chewers. Dentomaxillofac Radiol 2013;42:20120319.  Back to cited text no. 7
    
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Jackowski J, Jöhren P, Müller AM, Kruse A, Dirschka T. Imaging of fibrosis of the oral mucosa by 20 MHz sonography. Dentomaxillofac Radiol 1999;28:290-4.  Back to cited text no. 9
    
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Price RR, Jones TB, Goddard J, James AE. Basic concepts of ultrasonic tissue characterization. Radiol Clin North Am 1980;18:21-30.  Back to cited text no. 11
    
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Yeom SK, Lee CH, Cha SH, Park CM. Prediction of liver cirrhosis, using diagnostic imaging tools. World J Hepatol 2015;7:2069-79.  Back to cited text no. 13
    
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Rangaiah P, Annigeri RG, Lingappa A. Transcutaneous ultrasonographic assessment of oral submucous fibrosis: A preliminary study. Int J Oral Med Sci 2010;9:137-47.  Back to cited text no. 14
    
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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. 15
    
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James L, Shetty A, Rishi D, Abraham M. Management of oral submucous fibrosis with injection of hyaluronidase and dexamethasone in Grade III oral submucous fibrosis: A retrospective study. J Int Oral Health 2015;7:82-5.  Back to cited text no. 16
    
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Panigrahi R, Maheshwari A. A prospective, randomized double blind study comparing intralesional triamcinolone acetonide and hyaluronidase combination versus triamcinolone acetonide alone in the treatment of oral submucosal fibrosis. J Pharm Biomed Sci 2014;04:365-70.  Back to cited text no. 17
    
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    Figures

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

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



 

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