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Table of Contents   
ORIGINAL RESEARCH  
Year : 2011  |  Volume : 22  |  Issue : 4  |  Page : 530-536
Evaluation of oral submucous fibrosis using ultrasonographic technique: A new diagnostic tool


1 Department of Oral and Maxillofacial Pathology, Vishnu Dental College, Bhimavaram, India
2 Department of Radiology and Imaging, Meenakshi Ammal General Hospital, Chennai, India
3 Department of Oral and Maxillofacial Pathology, Meenakshi Ammal Dental College, Chennai, India
4 Department of Oral Medicine and Radiology, Meenakshi Ammal Dental College, Chennai, India

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Date of Submission28-Sep-2010
Date of Decision26-Oct-2010
Date of Acceptance11-Nov-2010
Date of Web Publication26-Nov-2011
 

   Abstract 

Aim: The aim of this study is to evaluate oral submucous fibrosis (OSMF) by clinical and histopathological examination, and compare the results with those from ultrasonographic technique.
Materials and Methods: 30 clinically diagnosed OSMF patients were subjected to both ultrasonographic and histopathological evaluation before treatment. Later, only ultrasonographical examination was done during 4 th and 8 th week of treatment. Prognosis of the lesion for the treatment was evaluated. Peak systolic velocity (PSV) of blood in the lesional area was statistically analyzed. 10 normal individuals without any mucosal lesions were considered as the control group.
Results: In normal individuals, ultrasonography delineates normal mucosa with uniform fine mottled appearance with interspersed hypoechoic areas. Color Doppler and spectral Doppler depicts uniform distribution of blood vessels and normal peak systolic velocity of blood respectively. All OSMF patients were diagnosed upon clinical and histopathological examination. Clinical examination revealed 14 individuals with unilateral palpable fibrotic bands and 16 individuals with bilateral fibrotic bands whereas, ultrasonographic evaluation revealed 6 individuals with unilateral fibrotic bands and 24 individuals were with bilateral fibrotic bands, which was statistically significant. Ultrasonography demonstrated number, length and thickness of the fibrotic bands. Color Doppler and spectral Doppler showed decreased vascularity and PSV in lesional area. Prognosis evaluation revealed 25 cases of good prognosis and 5 cases were showed poor prognosis. Wilcoxon Signed Ranks Test revealed no significant difference of PSV was seen in poor prognosis patients.
Conclusion: Ultrasonography is a non-invasive diagnostic tool for OSMF. It could be a better diagnostic tool compared to clinical and histopathological examination.

Keywords: Color Doppler, oral submucous fibrosis, spectral Doppler, ultrasonography

How to cite this article:
Manjunath K, Rajaram P C, Saraswathi T R, Sivapathasundharam B, Sabarinath B, Koteeswaran D, Krithika C. Evaluation of oral submucous fibrosis using ultrasonographic technique: A new diagnostic tool. Indian J Dent Res 2011;22:530-6

How to cite this URL:
Manjunath K, Rajaram P C, Saraswathi T R, Sivapathasundharam B, Sabarinath B, Koteeswaran D, Krithika C. Evaluation of oral submucous fibrosis using ultrasonographic technique: A new diagnostic tool. Indian J Dent Res [serial online] 2011 [cited 2019 Sep 18];22:530-6. Available from: http://www.ijdr.in/text.asp?2011/22/4/530/90287
Oral submucous fibrosis (OSMF) is a pre-cancerous condition predominantly seen among betel quid chewers in South Asian countries. [1],[2],[3] Clinically, the patient complains of burning sensation in mouth, excessive salivation or xerostomia. Later, the oral mucosa becomes stiff and opaque with fibrous bands on the buccal mucosa, soft palate, lips, and tongue. Histopathologically lamina propria shows fibrosis and hyalinization with a chronic inflammatory infiltrate and/or epithelial atrophy with loss of rete ridges. [4]

Biopsy for histopathological assessment is rarely performed in OSMF patients in the face of clinical diagnosis and the futility of indulging in a practice of biopsy has been shown. [5] The accuracy of clinical assessment has also been questioned because of intra- or inter - observer variability and possibility of impalpable fibrous bands in very early cases. [6] For these reasons, there has been a growing interest in the development of non-invasive diagnostic procedures. Ultrasonography (USG) is a non-invasive diagnostic tool commonly used for soft tissue pathology and its cystic changes. [7] Ultrasound is an acoustic energy which is also in the form of waves having a frequency above the human hearing range of 20KHz. In medical diagnosis, frequencies between 2-10MHz and only the longitudinal mode of ultrasound vibrations are used. Color Doppler is a combination of sonography plus Doppler system and the color coded representation of perfused areas. The assessment of the color distribution gives information about the vascularity in various lesions. Spectral Doppler depicts flow pattern and peak systolic velocity (PSV) of blood in an respective area. [8]

This study introduces a new method for evaluation of OSMF using Ultrasonography (2 Dimensional-2D and Dupplex Doppler including color flow imaging) and comparisons with clinical and histopathological examinations have been made.


   Materials and Methods Top


Our study includes 30 clinically diagnosed OSMF patients and 10 normal individuals, 20-40 years in age. All the patients were clinically examined and recorded in a structured performa designed for this study. Informed consent was taken from all the patients.

Normal individuals with no oral mucosal lesions and history of chewing areca nut or one of its commercial preparations were included in control group. Individuals with oral mucosal lesions, chronic illness and systemic diseases like diabetes mellitus, hypertension, pregnancy and lactating mothers, and any kind of allergy were excluded for control group.

Inclusion criteria of OSMF patients

  • A positive history of chewing areca nut or one of its commercial preparations.
  • Clinical features with burning sensation on eating spicy food, difficulty in swallowing and chewing, blanching of oral mucosa, palpable fibrous bands, restricted mouth opening (20-35 mm).


Exclusion criteria of OSMF patients

  • Age: <20yrs, >40yrs
  • Patients with chronic illness and systemic diseases like diabetes mellitus, hypertension, pregnancy and lactating mothers, and any kind of allergy.
  • Patients with manifestations like severe restricted mouth opening (<20 mm), immobility of the tongue, shrunken uvula and ulcerations.


Only buccal mucosa was considered for our study due to convenience for procedure and also to avoid bias. All individuals were subjected to clinical, ultrasonographic and histopathological evaluation before treatment. Later, only clinical and ultrasonographical examination was done during the 4 th and 8 th week of treatment, avoiding biopsy. All patients were subjected to complete treatment schedule and then evaluated. Clinical and ultrasonographic evaluation was statistically analyzed.

Treatment schedule

Intralesional injections of a combination of dexamethasone sodium phosphate 4 mg/ml and hyaluronidase 1500 IU twice a week for 8 weeks were given. At each visit, following topical application of lignocaine 2%, 1500 IU of hyaluronidase was dissolved in 2.0 ml of dexamethasone sodium phosphate in a 2 ml disposable syringe and the drugs were injected at multiple sites submucosally by means of a gauge 24 needle, taking care that not more than 0.2 ml solution was injected per site.

Evaluation

Ultrasonographic unit with color Doppler facilities and 9-5 MHz intra - cavitary convex transducer was used with water path. Glove finger filled with water served as the water path between transducer and oral mucosa. Water path helps in the proper alignment of transducer with mucosa and enhances clarity and details of the display. Ultrasonographic evaluation and interpretation was done by senior radiologist in the Department of Radiology and Imaging, Meenakshi Ammal General Hospital, Chennai. Patients were examined in supine position for convenience of examination. Glove finger filled with water was placed against buccal mucosa. Transducer with cellulose dextrose gel was placed on water path and analyzed [Figure 1]. Ultrasonographical examination was done before treatment and also during the 4 th and 8 th week of treatment. Mean PSV values of all the cases before, during and after treatment were statistically evaluated using Wilcoxon Signed Rank Test. In Wilcoxon Signed Rank test, P value ≤ 0.05 revealed that compared values are significant, whereas P value > 0.05 revealed that compared values are not significant statistically.
Figure 1: Ultrasonographic evaluation using intra-cavitary convex transducer and water path

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   Results Top


2D ultrasonography delineates normal mucosa with uniform fine mottled appearance with interspersed hypoechoic areas due to normal blood vessels and hyperechoic areas due to fibers, nerves, etc [Figure 2]a. Color Doppler shows the speed and direction at which the erythrocytes approach and move away from the transducer, and thus provides information necessary for the functional duplex sonography which is coded with blue and red color respectively [Figure 2]b. Spectral Doppler depicts flow pattern in the blood vessels and PSV. Spectral venous flow pattern in vein will show continuous wave pattern with average PSV of about 1-2 cm/sec [Figure 2]c. Spectral arterial pattern will show pulsatile wave pattern with average PSV of about 3-9 cm/ sec [Figure 2]d. PSV determines the velocity of blood flow and adequacy of vascularity in the respective area.
Figure 2a-d: Ultrasonographic evaluation of normal buccal mucosa

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On clinical examination, 14 individuals had unilateral palpable fibrotic bands and 16 individuals were with bilateral fibrotic bands. Ultrasonography examination revealed 6 individuals with unilateral fibrotic bands and 24 individuals with bilateral fibrotic bands and showed statistically significant (P ≤ 0.05) results. Histopathologically, all cases were confirmed with clinical diagnosis of oral submucous fibrosis. Ultrasonography demonstrates the number, length, thickness of the fibrotic bands and pattern of overall vascularity in the affected area [Figure 3]a-c. Vascularity of mucosa overlying the bands was found to be decreased with reduced flow velocity. Vascularity of mucosa in between bands was found to be normal.
Figure 3a-c: Ultrasonography demonstrates number (arrows), length (dot line) and thickness (dot line) of the fibrotic bands and pattern of vascularity in an oral submucous fibrosis lesion

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Ultrasonographic examination before treatment revealed hyperechoic fibrous bands in 29 patients (Average thickness about 1 mm) where as one case showed a diffuse fibrotic patch [Figure 4]a-c. USG evaluation of OSMF during and after treatment revealed good prognosis in 25 cases [Figure 5] and poor prognosis in 5 cases [Figure 6]. Former cases showed slight regression of clinical signs and symptoms, and improvement in mouth opening after 4 weeks of treatment, whereas there was a complete regression of signs and symptoms, and mouth opening was normal (>40 mm) after 8 weeks of treatment. Later cases showed no change in clinical signs and symptoms, and mouth opening even after 8 weeks of treatment. Out of 25 cases of good prognosis, 9 cases showed mean PSV of 1.23 cm/sec before treatment with PSV values of 1.44 cm/sec and 1.71 cm/sec on 4th and 8th week of treatment respectively. 16 cases showed mean PSV of 0.83 cm/sec before treatment with PSV values of 1.21 cm/sec and 1.42 cm/sec on 4 th and 8 th week of treatment, respectively. 5 cases of poor prognosis showed mean PSV of 0.76 cm/sec before treatment with PSV values of 0.77 cm/sec and 0.79 cm/sec on 4 th and 8 th week of treatment respectively [Table 1]. Statistical analysis using Wilcoxon Signed Rank test revealed that significant difference was present in mean PSV values of good prognosis patients, whereas no significant difference was seen in mean PSV values of poor prognosis patients upon our treatment schedule.
Figure 4a-c: Ultrasonography demonstrates diffuse fibrotic patch (crossing dot lines) and diminished vascularity in an oral submucous fibrosis lesion

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Figure 5: Ultrasonographic evaluation of oral submucous fibrosis revealing good prognosis for the given treatment schedule

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Figure 6: Ultrasonographic evaluation of oral submucous fibrosis revealing poor prognosis for the given treatment schedule

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Table 1: Prognostication of oral submucous fibrosis using ultrasonography

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   Discussion Top


USG is based on the principle of inverse piezoelectric effect. [9] Ultrasonography is a valuable diagnostic tool in various aspects of medicine like liver diseases, renal diseases, prostate malignancies, salivary gland diseases, pregnancy etc. [10] The stage of liver fibrosis shows important prognostic information as it is closely related to the risk for development of liver cirrhosis. [11] The accuracy of liver biopsy for assessing liver fibrosis has been questioned because of sampling errors and intra- or inter-observer variability that can lead to over or underestimation of fibrosis stage. [12] Recently, non-invasive procedures like normal USG, modified high frequency USG and fibroscan are routinely used for the assessment of liver fibrosis. [13]

Li et al., used ultrasonography for monitoring localized scleroderma. USG detected several abnormalities in active lesions including decreased blood flow, increased echogenicity and loss of subcutaneous fat and reduction in lesion size during treatment. [14] Hesselstrand R et al., used high frequency ultrasonography for assessment of systemic sclerosis (SSc). [15] This intended us to evaluate OSMF using USG as a diagnostic tool. To the best of our knowledge, no literature is available regarding utility of USG in the evaluation of OSMF. In this study, OSMF showed increased hyperechoiec areas (representing fibrous bands or diffuse fibrosis) with normal/decreased vascularity and PSV.

Recently, Srinivas et al., used USG for studying anatomy of cheek region, differentiation of cellulitis and abscess in buccal space region, and investigated the use of ultrasound in the diagnosis of inflammatory swellings of cheek region. [16] Rajaram et al., introduced M-mode Echomyographic technique, a modified ultrasonographic technique, for the functional assessment of striated muscles in head and neck region. [17] In this study, we used the routine 2D USG with water path to evaluate normal tissues and OSMF in buccal mucosa.

In some OSMF cases, USG delineated feeble fibrotic bands in clinically appearing normal buccal mucosa; thereby it scores over clinical assessment of OSMF. Its demonstration of adequate vascularity in the affected area implies satisfactory response to treatment. Similarly, patients depicting decreased vascularity had poor response to treatment. USG demonstration of fibrosis and vascularity status during and post treatment period helps to monitor the efficacy of the treatment instituted. Patients with poor vascularity in the affected area and poor response to treatment imply that the treatment schedule should be altered. USG monitoring during treatment helps to alter and assess the efficacy of treatment schedule instituted. In our study, out of 25 cases of good prognosis, 9 cases showed normal mean PSV (1.23 cm/sec) before treatment and improvement in PSV was seen upon treatment. 16 cases showed decreased mean PSV (0.83 cm/sec) before treatment where as improvement in mean PSV was seen upon treatment. 5 cases of poor prognosis showed decreased mean PSV (0.76 cm/sec) before treatment and mean PSV remained decreased on 4 th and 8 th week of treatment (0.77 cm/sec and 0.79 cm/sec respectively). Statistical analysis revealed that significant difference was present in mean PSV values of good prognosis patients whereas no significant difference was seen in mean PSV values of poor prognosis patients upon our treatment schedule. This revealed that poor prognosis cases did not respond to our treatment schedule, so alteration in treatment schedule by increasing the dose, frequency or alteration in drugs is necessary to treat these cases.

Histopathological evaluation of all cases provided confirmatory evidence of fibrosis in the connective tissue. USG provided the same information non-invasively with the advantage of possible repeated studies during treatment and post treatment periods. USG takes less time to study a larger area whereas the former takes longer time to study a limited area. In USG, fibrous bands can be studied in relation to vascularity and blood flow in that region, which is not possible in routine histopathological procedures. Prognosis of OSMF during treatment can be assessed in USG.

Modified USG (Sandwich technique) can be used in patients with markedly restricted mouth opening due to severe OSMF, the efficacy of which is yet to be revealed in our further studies.


   Conclusion Top


We consider that, USG is a valuable, radiation free and non-invasive diagnostic tool for the evaluation of OSMF. In some OSMF cases, USG evaluates feeble fibrotic bands in clinically appearing normal buccal mucosa. USG helps in monitoring the progress or otherwise of the lesion. It helps in alteration of the treatment schedule in selected cases and allows for post treatment follow-ups and assessment. USG provides a more accurate evaluation of fibrous bands and vascularity in OSMF cases. So, it could be a better diagnostic tool compared to clinical and histopathological examination.

 
   References Top

1.Utsunomiya H, Wanninayeke MT, Kazufumi O. Extracellular matrix remodeling in oral submucous fibrosis: Its stage specific modes revealed by immunohistochemistry and Insitu hybridization. J Oral Path Med 2005;34:498-507.  Back to cited text no. 1
    
2.Gupta PC, Warnakulasuriya S. Global epidemiology of arecanut usage. Addict Biol 2002;7:77-83.  Back to cited text no. 2
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3.Paymaster JC. Cancer of the buccal mucosa: A clinical study of 650 cases in Indian patients. Cancer 1956;9:431-5.  Back to cited text no. 3
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4.Rajendran R, Sivapathasundharam B. Shafer's text book of Oral Pathology. 6th ed. Philadelphia: Elsevier Publ; 2009. p. 97-9.  Back to cited text no. 4
    
5.Shah N, Ranikumar, Singh MK. Hematological and histological studies of OSMF. J Ind Dent Assoc 1993;64:383-8.  Back to cited text no. 5
    
6.Haider SM, Merchant AT, Fikree FF. Clinical and functional staging of OSMF. Br J Oral Maxillofac Surg 2000;38:12-5.  Back to cited text no. 6
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7.Carol RM, Stephanie IW, Charbineau JW. Diagnostic ultrasound. 4 th ed. Missouri: Mosby Publ 1991. p. 1-4.  Back to cited text no. 7
    
8.Hagen-Ansert SL. Textbook of diagnostic ultrasound. 5 th edition. Missouri: Mosby Publ 2001. p. 3-15.  Back to cited text no. 8
    
9.Palmer PE. Manual of diagnostic ultrasound. New Millennium edition. Geneva: WHO Publ; 2006. p. 3-16.  Back to cited text no. 9
    
10.William AR, George G, Yong HA, Elias K. CT of fibrous tissue and tumours with sonographic correlation. AJR Am J Roentgenol 1986;147:1067-74.  Back to cited text no. 10
    
11.Rudolf ES, Carolin L. Non-invasive diagnosis of hepatic fibrosis in chronic hepatitis C. World J Gastroenterol 2007;13:4287-94.  Back to cited text no. 11
    
12.Bourliere M, Penaranda G, Oules V, Castellani P. Combining non invasive methods for assessment of liver fibrosis. Gastroenterol Clin Bio; 2008;32:73-9.  Back to cited text no. 12
    
13.Marin JC, Solis JA. Non-invasive assessment of liver fibrosis, serum markers and transient elastography (fibroscan). Rev Esp Enferm Dig 2009;101:787-99.  Back to cited text no. 13
    
14.Li SC, Leibling MS, Haines KA. Ultrasonography is a sensitive tool for monitoring localized scleroderma. Rheumatology 2007;46:1316-7.  Back to cited text no. 14
    
15.Hesselstrand R. High frequency ultrasound of skin involvement in systemic sclerosis reflects oedema, extension and severity in early disease. Rheumatology 2008;47:84-7.  Back to cited text no. 15
    
16.Srinivas K, Sumanth KN, Chopra SS. Ultrasounographic evaluation of inflammatory swellings of buccal space. Indian J Dent Res 2009;20:458-62.  Back to cited text no. 16
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17.Rajaram PC, Naidu ME, Rao SP, Sindhuvenugopal. M-Mode echomyography: A new technique for the functional assessment of striated muscles. Indian J Radio Imaging 2002;12:537-41.  Back to cited text no. 17
    

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Correspondence Address:
K Manjunath
Department of Oral and Maxillofacial Pathology, Vishnu Dental College, Bhimavaram
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-9290.90287

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    Figures

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    Tables

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