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Copyright ©2013

Review Article

J Res Adv Dent 2014; 3:2:72-75.

An outline of existing clinical classification system for oral sub

mucous fibrosis

Nidhi Thakur1* Vishal Kumar2

1Senior Lecturer, Department of Oral Medicine and Radiology, Dr. B R Ambedkar Institute of Dental Sciences and Hospital, Patna, Bihar, India. 2Reader, Department of Orthodontics, Dr. B R Ambedkar Institute of Dental Sciences and Hospital, Patna, Bihar, India.

ABSTRACT

Objectives: Oral submucous fibrosis remains an enigma, with a poorly defined classification system and elusive

pathogenesis. Many attempts have been made to classify OSMF, some based on clinical criteria and some on

histopathological criteria. Some authors have classified it based on the functional aspects. But none of these

classification systems have a universal acceptance. Here is an attempt to compile the different systems of OSMF

classification for the ease and better understanding of the clinicians.

Keywords: Oral submucous fibrosis, potentially malignant disorder.

INTRODUCTION

Oral submucous fibrosis is a potentially

malignant disorder that is characterized by

blanching and stiffness of oral mucosa, trismus, and

burning sensation in the mouth. It also produces

hypomobility of the soft palate and tongue, and loss

of gustatory sensation. Occasionally there can be

mild hearing impairment due to blockade of the

eustachian tube. Although the etiology is not very

clear but a definitive association of the same with

areca nut (Areca catechu) consumption in variable

forms has been established by many studies1-5.

Some cases of oral submucous fibrosis have been

reported in patients without any habit of areca nut

consumption6. It affects people of all age groups and

both the sex but is more prevalent in males in

second and third decade. The malignant potential

for oral submucous fibrosis is considered high7.

Extensive studies done on the

etiopathogenesis of the disease have observed an

evidence of OSMF being a mucosal change

secondary to chronic iron and /or vitamin B

complex deficiency5.It has been suggested that the

disease is an Asian analogue of sideropenic

dysphagia. The biological basis for OSMF remains

unclear but cytotoxic, apoptotic and proliferative

effects from areca nut agents have been proposed

for it 8-11. Active oxygen species and reactive free

radicals mediate alterations that lead to mutations

and produce the genotypic and phenotypic

manifestations of the disease.

Both surgical and pharmacological

treatments have been tried in the management of

OSMF. Surgical treatment by excision of fibrous

tissues is effective but is often followed by relapse.

They are also inaccessible in certain backward

communities where OSMF is a common entity.

Conservative management has shown significant

improvement in mouth opening and providing

symptomatic relief to the patients14 to 16.

Physiotherapy along with micronutrients

supplements has also been reported to show

significant improvement in mouth opening in these

patients17, 18, 19.

Outline of the clinical classification systems:

73

Though oral submucus fibrosis has been classified

based on its clinical symptoms as well as

histopathological features but clinical staging is

gaining significance. This is because biopsy per se

for diagnosis has been largely abandoned as it is

seen to cause further fibrosis and scarring. The

existing clinical classification system has been

placed here arbitrarily in two groups (Table 1).

Classifications given before

year 2000

Classifications given

after year 2000

1. J V Desa(1957) 1. Rangnathan K et al

(2001)

2. Pindborg JJ(1989) 2. Rajendran et

al(2003)

3. S K Katharia(1992) 3. Nagesh and

Bailoor(2005)

4. Lai DR et al(1995) 4. Tinky Bose & Anita

Balan

5. R Maher(1996) 5. Kiran kumar et al

(2007)

6. Chandramani more

et al (2011)

Classification by J V Desa (1957)

Stage I- stomatitis & vesiculations

Stage II- Fibrosis

Stage III- As its sequelae

Classification by Pindborg JJ (1989)

Stage I- Stomatitis includes erythematous mucosa,

vesicles, mucosal ulcers, melanotic mucosal

pigmentations and mucosal petechiae.

Stage II-Fibrosis occurring in the healing vesicles

and ulcers, is the hallmark of this stage.

Early lesions demonstrate blanching of the

oral mucosa.

Older lesions include vertical and circular

palpable fibrous bands in the buccal

mucosa and around the mouth opening or

lips. This results in a mottled marble like

appearance of the mucosa because of the

vertical thick fibrous bands in association

with a blanched mucosa.

Stage III- Sequelae of OSMF are as follows

Leukoplakia as found in more than 25% of

individuals with OSMF

Speech and hearing defects may occur

because of involvement of the tongue and

the Eustachian tubes.

SK Katharia classification et al (1992)

Score 0- mouth opening is greater than 41 mm

Score 1- mouth opening between 37 to 40 mm

Score 2- mouth opening between 33 to 36 mm

Score 3- mouth opening between 29 to 32 mm

Score 4- mouth opening between 25 to 28 mm

Score 5- mouth opening between 21 to 24 mm

Score 6- mouth opening between17 to 20 mm

Score 7- mouth opening between13 to 16 mm

Score 8- mouth opening between 9 to 12 mm

Score 9- mouth opening between 5 to 8 mm

Score 10- mouth opening between 0 to 4mm

Lai DR conducted a study and dvided the patients

based on the interincisal distance as

Group A- Mouth opening greater than 35mm

Group B- Mouth opening between 30 to 35mm

Group C – Mouth opening between 20 to 25mm

Group D – Mouth opening less than 20mm

R Maher has given a classification based on area of

involvement of the oral cavity

Involvement of 1/3rd or less of the oral cavity

74

Involvement of 1/3rd to 2/3rd of the oral

cavity(if 4 to 6 intra oral sites are involved)

Involvement of greater than 2/3rd of the oral

cavity.

Ranganathan K et al used a baseline study on the

mouth opening parameters of normal patients and

divided the OSMF patients as

Group I- Only symptoms with no restriction of

mouth opening

Group II- Limited mouth opening 2o mm and

above

Group III- Mouth opening less than 20 mm

Group IV – OSMF advanced with limited mouth

opening along with precancerous or cancerous

changes seen throughout the mucosa.

Rajendran R classification reported the clinical

features of OSMF as:

Early OSMF- Burning sensation in the mouth.

Blisters especially on the palate, ulceration or

recurrent generalised inflammation of the oral

mucosa, excessive salivation, defective

gustatory sensation and dryness of mouth

present.

Advanced OSMF- Blanched and slightly opaque

mucosa, fibrous bands in buccal mucosa

running in vertical direction. Palate and the

faucial pillars are the areas involved. Gradual

impairment of tongue movement and difficulty

in mouth opening.

Tinky Bose and Anita Balan classification of OSMF

Group A – mild cases

Group B – moderate cases

Group C – severe cases

Kiran Kumar et al

Stage I (Mouth opening greater than 45mm)

Stage II (Restricted mouth opening 20 to

40mm)

Stage III (Mouth opening less than 20mm)

Chandramani More et al classification20 (2011)

A. Clinical Staging:

Stage I (S1) –stomatitis and blanching

Stage II (S2) - Presence of palpable fibrous bands in

buccal mucosa and or oropharynx with or

without stomatitis.

Stage III- Involvement of other part.

Stage IV (S4)-

Any of the above stage along with presence of

potentially malignant disorder.

Presence of oral carcinomas.

Functional classification (Based on interincisal

distance)

M1- Interincisal mouth opening up to or > 35mm

M2- Interincisal distance between 25 to 35mm

M3- Interincisal distance between 15 to 25mm

M4- Interincisal distance of less than 15mm

CONCLUSION

The purpose of the present article is to outline the

existing clinical classification for the ease of

diagnosis and treatment of oral submucous fibrosis.

CONFLICT OF INTEREST

No potential conflict of interest relevant to this

article was reported.

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