ORIGINAL ARTICLE

Fibrotomy with diode laser (980 nm) and habit correlationin oral submucous fibrosis: a report of 30 cases

Sunita Gupta1 & Prerna Piyush1& Anshul Mahajan1

& Sujata Mohanty2 & Sujoy Ghosh1& Khushboo Singh1

Received: 13 December 2017 /Accepted: 1 May 2018 /Published online: 8 June 2018# Springer-Verlag London Ltd., part of Springer Nature 2018

AbstractTo evaluate the efficacy of laser fibrotomy in patients with oral submucous fibrosis (OSMF) and also to correlate the habitvariables causing OSMF. Thirty patients diagnosed clinically and histopathologically with OSMF were included in the study.Laser fibrotomy was done under local anesthesia using Zolar diode laser (980 nm frequency) at 2-W power in contact mode withfibro-optic cutting tip. The patients were advised to practice mouth-opening exercises rigorously, and topical corticosteroid wasgiven for burning sensation and pain for 6 months. Pre- and post-treatment comparison of mouth opening, burning sensation,tongue protrusion, and cheek flexibility was analyzed after a follow-up period of 9 months. After a follow-up period of 9 monthsfrom the surgical intervention, the mean value of difference in pre- and post-treatment of VAS score, mouth opening, and tongueprotrusion was found to be 3.3 ± 2.1, 7.7 ± 5.1, 1.6 ± 2.7, and 0.38 ± 0.61 respectively. Using the Wilcoxon signed rank test, allthe above difference in mean was found to be significant with p value < 0.05. With above suggested significant results, lasers canprovide an alternative and better means for surgical fibrotomy, relieving trismus in moderate OSMF as they are minimallyinvasive, cause less hemorrhage, and have faster healing and minimal surgical site scaring and relapse.

Keywords Oral submucous fibrosis . Diode laser . Fibrotomy . Habit correlation

Introduction

Oral submucous fibrosis (OSMF) is a chronic disease of oralmucosa characterized by inflammation and progressive fibro-sis of lamina propria and deeper connective tissues, followedby stiffening of an other wise yielding mucosa resulting indifficulty in opening the mouth [1, 2]. It is a crippling diseasein terms of progressive reduction in mouth opening, ulcera-tions, and burning sensation of the oral mucosa leading todifficulty in eating and swallowing, nutritional deficiency,poor oral hygiene, and impaired ability to speak [3].

The malignant transformation rate has been reported as 3–19% [4, 5]. A wide variety of treatments including medical,physical, and surgical treatments have been instituted for its

management over the past few decades, but so far, evidence-based treatment protocol is still lacking. The literature has lackof reliable and valid data about the effectiveness of specificinterventions for the management of OSMF [6].

The mainstay of treatment for initial stage of OSMF isconservative like cessation of habit, physiotherapy, and med-ical, which includes anti-oxidant therapy, nutritional, vitamin,and iron supplements along with topical corticosteroids [7]. Inthe moderate subgroup along with the medical therapy ad-juncts like intralesional injections of corticosteroids, hyaluron-idase, or placentrex, systemic corticosteroids, immunomodu-lators, and pentoxifylline are given [7]. Surgical managementis usually implemented in advanced stage of the disease wheresufficient mouth opening can only be achieved by completerelease of fibrotic bands and reconstruction of resultant defectwith split thickness skin graft, buccal fat pad, micro-vascularfree radial forearm flap, tongue flap, or nasolabial flap [8].Currently, managing the group II and III OSMF is more chal-lenging as conservative treatment does not provide much ben-efit and aggressive surgical techniques are not justified inthese cases.

Lasers can be used as an alternative for surgical fibrotomyas they have the advantage of providing a bloodless field, are

* Prerna Piyushprernasng@gmail.com

1 Department of Oral Medicine & Radiology, Maulana Azad Instituteof Dental Sciences, Bahadur Shah Zafar Marg, New Delhi 110002,India

2 Department of Oral and Maxillofacial Surgery, Maulana AzadInstitute of Dental Sciences, New Delhi, India

Lasers in Medical Science (2018) 33:1739–1745https://doi.org/10.1007/s10103-018-2531-8

minimally invasive, and have less fibrosis and minimal scar-ring after complete healing. Recently, uses of diode 810–980 nm [9], KTP—532 nm [10, 11], and Er,Cr:YSGG—2780 nm [12, 13] have been undertaken for the managementof reduced mouth opening. One of the important aspects ofmanagement is to restore functionality by increasing theamount of mouth opening, which in turn also acts as a moti-vational factor for quitting habit and improving the nutritionalstatus. It is a chronic disease and no single medical manage-ment can lead to complete reversal of symptoms. Moreover,the long duration of medical treatment leads to increased ex-pense, non-compliance, and systemic adverse effects [14]. Insuch a situation, lasers can be used as a safe, cost-effectivetreatment modality with minimal side effects.

Here, we present a case study of 30 patients with OSMFtreated with diode laser under local anesthesia followed byactive mouth-opening exercises along with habit cessationand topical application of corticosteroid. The treatment out-comes were assessed in terms of mouth opening, burning sen-sation, tongue protrusion, and cheek flexibility.

Material and methods

Sample selection

The study was conducted in the Department of Oral Medicineand Radiology, Maulana Azad Institute of Dental Sciences,New Delhi, India, over a period of 1 year from December2015 till January 2017. The proposed study was approvedby the Ethical Committee of the University of Delhi (India).

Inclusion criteria

1. Patients showing clinical characteristic of OSMF (arecanut habit with blanching and palpable fibrous bands)whose diagnosis was confirmed histopathologically [15]

2 . No ev i d e n c e o f d y s p l a s i a o r ma l i g n a n c yhistopathologically

3. The patients belonging to group II and group III (moder-ate OSMF) according to Khanna and Andrade’s clinicalclassification [16]

Exclusion criteria

1. The patients who were not willing2. Those with cardiac, respiratory, renal, and hepatic

diseases

A detailed history of smoking and smokeless habit formswas recorded for each patient [Table 1], and informed consentfor participation in the study was taken.

Clinical examination

Detailed clinical examination in terms of burning sensation,mouth opening, tongue protrusion, and cheek flexibility wasperformed.

1. Burning sensation: It was recorded using VAS scale (0–10).

2. Mouth opening: It was measured using a geometric divid-er and scale between the mesioincisal edge of the upperleft central to the mesioincisal edge of the lower left cen-tral incisor tooth in millimeters.

3. Tongue protrusion: It was recorded by measuring the dis-tance from the mesial contact area of the upper centralincisors to the tip of protruded tongue and was recordedin units of millimeter.

4. Cheek flexibility: Two points were measured between onethird the distance from the angle of the mouth on a linejoining the tragus of the ear and the angle of the mouth(v1); the subject was then asked to blow his cheeks fully,and the distance was measured between the two pointsmarked on the cheek (v2). Cheek flexibility = v2 − v1.

Surgical procedure

Laser fibrotomy was done under local anesthesia (2% w/vlignocaine and adrenaline in ratio 1:2,00,000 manufacturedby Kwality Pharmaceuticals LTD., Amritsar, India) using a980-nm solid-state diode laser for oral soft tissues (Model—Photon plus, Zolar Technology & Manufacturing Co. Inc.,Mississauga, ON, Canada) [Fig. 1a]. The laser was used ac-cording to the manufacture’s manual instructions. A metalhandpiece with disposable cutting fiber of width 400 μm di-ameter was used in continuous wave emission mode at 2-Wpower in contact mode. The total energy was calculated as 4 Jand the fluence was 50 J/cm2. Complete epithelialization ofthe mucosal defects took place in approximately 2–3 weeks inall cases.

The patients were advised to practice mouth-opening exer-cises rigorously, and topical corticosteroid (triamcinoloneacetonide gel 0.1% as topical application thrice daily) wasgiven for burning sensation and pain for 6 months.

Outcome measures

Parameters of burning sensation, mouth opening, tongue pro-trusion, and cheek flexibility were recorded during clinicalexamination before starting the treatment, at days 7 and 14and every month until 9 months post treatment [Fig. 2b].Comparing the preoperative and 9 months post-operative dataresults were assessed [Fig. 3a, b]. Patients are still under

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follow-up at every 3 months for review and assessment of anymalignant transformation.

Results

The age of patients participating in the study ranged from 20to 50 years. Out of 30 patients enrolled for the study, a max-imum of 46.7% (n = 14) were in the age group of 21–30 yearswith mean age being 29.7. The study comprised 73.3% (n =22) of male and 26.6% (n = 8) of female gender. The habithistory of the patients suggested that all the 30 patients prac-ticed smokeless habit form, 73.3% (n = 22) of which wasgutka. 13.3% (n = 4) had a habit of tobacco chewing, 3.3%(n = 1) had a paan chewing habit, and 10% (n = 3) had com-bination of tobacco and betel nut chewing [Fig. 4]. 6.7% (n =2) patients practiced bidi smoking along with smokeless habit

forms. Bilateral involvement of fibrotic bands in buccal mu-cosa was most common, seen in 93.3% (n = 28) of the cases.Twenty-two cases were in group III and eight were in group IIas per OSMF classification of Khanna and Andrade [16].

Histopathologically 23.3% (n = 7) cases were diagnosed asearly, 70% (n = 21) as moderately advanced, and 6.7% (n = 2)as advanced OSMF.

After a follow-up period of 9 months from the surgicalintervention, the mean value of difference in pre- and post-treatment of VAS score, mouth opening, and tongue protru-sion was found to be 3.3 ± 2.1, 7.7 ± 5.1, 1.6 ± 2.7, and 0.38 ±0.61 respectively [Fig. 5]. Using the Wilcoxon signed ranktest, all the above difference in mean was found to be signif-icant with p value < 0.05 [Table 2].

Laser fibrotomy was done as a chair-side procedure underlocal anesthesia with an average operating time of 1 h. Post-operative complications following fibrotomy like

Fig. 1 Photograph showing a980-nm diode laser unit, b lasertip initiation on an articulatingpaper, and c, d laser fibrotomy ofthe right and left buccal mucosarespectively

Table 1 Forms of habit and its constituents

Forms of habit Constituents

Paan masala [17] Areca nut, catechu, cardamom, lime, natural and artificial perfuming, and flavoring materials

Gutkha [17] Areca nut, catechu, cardamom, lime, natural and artificial perfuming, and flavoring materials + chewing tobacco

Paan/betel quid [17] Mixture of areca nut, catechu, and slaked lime wrapped in a betel leaf. In India, most habitual chewers of betel quid add tobacco

Tobacco [18] Chewing—in the form of loose leaf, plug, or twistSnuff—finely cut or ground tobacco that can be dry or moist

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hemorrhage, post-operative infection, nerve damage, anddamage to adjacent tissues and teeth were not recorded inany case.

Discussion

OSMF is one of the most prevalent premalignant conditions inIndia, which is easy to diagnose but difficult to manage. It hasalso been referred to as an epidemic in India [17]. Literaturesuggests variable gender distribution. Some epidemiologicalsurveys in India have shown female predominance [18, 19]whereas other shows male predominance [20]. In the presentstudy, out of 30 patients, 22 were male and 8 were female. Themean age in the study was 29.7. The reason for younger agegroup and male predominance is due to marketing and easyavailability of gutkha and other related products amongyoungsters. Moreover, males are the working gender andmoney earner among Indian subcontinent [20].

All the patients had habit history of chewing some form ofbetel nut and tobacco. Maximum number of patients 73.3%(22) had habit of chewing gutka. 13.3% (4) used tobacco,3.3% (1) had a paan chewing habit, and 10% (3) used a com-bination of tobacco and betel nut. 6.7% (2) patients practiced

bidi smoking along with smokeless habit forms. Gutkhachewing produces OSMF earlier as compared to other smoke-less habit forms. The reason for increased severity and risk ofdeveloping OSMF in gutkha chewers is due to the abrasivenature of areca nut, which is the main constituent of gutkhaand pan masala, which causes continuous local trauma andirritation to the oral mucosa leading to morphological changes[21]. The other reason is more dry weight of areca nut releas-ing high amount of arecoline [22]. Although smoking is notdirectly related to the development of OSMF, when patientshave coexisting smoking habit along with smokeless form,this poses them to a high risk of malignant changes, as tobaccosmoking has been reported to act jointly with betel quid in thegenesis of oral and esophageal cancers [23].

The various conservative treatment options available fortreating OSMF are not very effective in relieving trismus.Traditional methods of relieving fibrotic band using knife leadto increased intraoperative bleeding and difficulty in accessi-bility due to trismus. Although electrosurgical techniques pro-vide bloodless field, the tissue damage produced is severeleading to post-operative fibrosis and dehiscence.Introduction of laser for relieving trismus in OSMF providesa minimally invasive, cost- and time-effective alternative toconventional surgical techniques which has associated risk of

Fig. 2 Photograph showing amucosa after incision with diodelaser and b healed mucosa withminimal scarring after 9 monthsfollow-up

Fig. 3 Photograph showing apreoperative mouth opening andb post-operative mouth openingafter 9 months follow-up

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general anesthesia and donor site morbidity and is a time-consuming procedure. The most commonly used lasers forfibrotomy in OSMF are Er,Cr:YCCG—2780 nm [12, 13],KTP 532 nm [10, 11], and the diode laser [9]. Until now, thereis no scientific basis for the selection of type of laser, and thechoice is mostly dependent on its availability in medical setup[24]. In our study, almost all the patients benefitted from in-crease in mouth opening. Topical corticosteroid was given asan adjunctive treatment for pain and inflammation control posttreatment as well to improve burning sensation. In addition tothis, patients were periodically monitored and motivated topractice mouth-opening exercises which also helped in

preventing relapse of treatment. It was observed that in theinitial phase of post-treatment period, there was a comparativedecrease in mouth opening and increase in VAS score becauseof wound healing due to secondary intension following whichthere was a progressive increase in mouth opening and de-crease in burning sensation. The mean improvement in mouthopening was recorded as 7.7 and mean decrease in VAS scorewas 3.3. The outcome was also measured on the basis ofadditional criteria of tongue protrusion and cheek flexibilitywhich also showed improvement with mean value of 1.6 and0.38 suggesting that release of fibrotic bands in buccal mucosaenhanced the flexibility of cheek as well as improved

Fig. 5 Graph showing comparison of pre- and post-operative clinical findings

Fig. 4 Pie diagram showingsmokeless habit form distribution

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restricted tongue protrusion to some extent. None of the pre-vious conducted studies on laser fibrotomy assessed the out-come measures based on the abovementioned criteria as themain objective was to measure only an increase in mouthopening.

In our experience, diode laser fibrotomy under local anesthe-sia is not feasible in group IV cases due to limited accessibilitybut can be a sustainable option in group II and III OSMF. It iseasy to use and gives precise line of cutting without the risk ofdamaging the adjacent structure or underlying muscle. As it is abloodless procedure and a coagulum of protein deposits on thesurface, spontaneous epithelization takes place and the affectedarea is visible to inspection in contrast to conditions where bulkyflaps might hide developing malignancy. Diode laser can beeasily performed in a dental setup or minor operating roomunder local anesthesia, making it cost-effective. As majority ofthe patients suffering from this disease are from lower socioeco-nomic strata, diode laser fibrotomy can offer affordable treat-ment adjunct. It also acts as a motivational factor as patient canappreciate increase in mouth opening which further encouragethem to practice mouth-opening exercise, to improve nutritionalstatus and refrain from starting the habit again.

Conclusion

With the above suggested significant results, there is no doubtthat lasers can provide as an alternative and better means forsurgical fibrotomy and relieving trismus in moderate OSMFcases as they are minimally invasive, cause less hemorrhage,and have short operating time, faster healing, less morbidity,and minimal surgical site scaring and relapse. Moreover, inreview of predominance of this disease in our subcontinent,standardized protocols and procedures for surgical interven-tion have to be clearly outlined and established based on con-trolled trials and large sample size.

Compliance with ethical standards

Conflict of interest The authors declare that they have no conflict ofinterest.

Ethical approval The study was approved by the Ethical Committee ofthe University of Delhi (India) and was in accordance with the 1964

Helsinki declaration and its later amendments or comparable ethicalstandards.

Informed consent Informed consent was taken from every patient en-rolled for the study.

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Table 2 Outcome assessment

Assessment criteria Pretreatment mean value Post-treatment mean value Difference in mean value p value (Wilcoxon signed rank test)

Mouth opening 23.08 30.82 7.7 .0001

VAS 5.97 2.60 3.3 .0001

Tongue protrusion 27.40 29 1.6 .005

Cheek flexibility 0.98 1.37 0.38 .004

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