People’s Journal of Scientific Research / Volume 16 / Issue 1 / Jan-June 2023
09
Research Article
Oral Submucous Fibrosis: Clinical Stage, Functional
Stage and Histopathological Grade Correlation
Tarjani Shankar1, Swati Saawarn1, Einstein A2, Anushree Rathore1, Shubhangi D Mishra3,
Ruchita Khade1
1
Department of Oral Pathology and Microbiology, Bhabha College of Dental Sciences, Bhopal, ,
2
Department of Oral Pathology, Thai Moogambigai Dental College and Hospital, Chennai,
3
Department of
Oral Pathology and Microbiology, NIMS Dental College and Hospital, NIMS University Rajasthan
ABSTRACT:
Background- Oral submucosal fibrosis (OSMF) is a common precancerous condition predominantly
affecting the oral cavity. There are several contributing factors to its pathogenesis, areca nut chewing
being the primary culprit. OSMF reversal is difficult once the disease sets in. Hence, after its diagnosis,
staging becomes imperative as it affects the treatment plan. Several classification methods have been
developed by various authors to categorize the disease based on its clinical, functional, and
Histopathological characteristics. The main aim to conduct this study was to correlate clinical and
histopathological staging.
Materials & Methods- This study involved 30 patients who had been diagnosed with OSMF both
Clinically and Histopathologically. All 30 patients were classified and were categorized according to
their clinical and functional stages after inspection. Following this, histopathological grading was done.
Results- The statistical analysis showed that there was a wide similarity between the clinical and
functional staging. However, no significant similarity or correlation was found between the clinical and
functional staging with its corresponding histopathological grades.
Conclusions- Our study concluded that there is strong correlation between clinical and functional
grading.
KEYWORDS: clinical staging; functional staging; histopathological grading; oral submucous fibrosis
Address for correspondence : Dr Tarjani Shankar, Department of Oral Pathology and Microbiology, Bhabha College of Dental
Sciences, Bhopal-462026 , E-mail: tarjani30aug@gmail.com
Submitted: 22.05.2023, Accepted: 14.06.2023, Published: 26.06.2023
INTRODUCTION:
Oral submucous fibrosis (OSMF) is a
precancerous condition that affects the oral cavity[1]
and was first mentioned by Schwartz in 1952 under the
term “atrophica idiopathica mucosae oris”.[2] It is a
iron, zinc, essential vitamins, and capsaicin in chilies,
may also play a role.[9-12] Various classification systems
have been put forth by different authors, which
categorize patients based on their clinical signs and
symptoms, functional abilities and histopathological
slow-developing, chronic disease characterized by findings.[13] The main purpose of the classification
inflammation and fibrosis in the submucosal tissues.[3]
Joshi later coined the term “OSMF” in 1953.[4] Studies
have confirmed that areca nut is the main cause of
OSMF,[5-8] although other factors such as deficiencies in
system is to identify this premalignant disorder in its
early stage and to formulate a treatment plan
accordingly for patient's speedy recovery.[14],[15] This
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How to cite this article: Shankar T, Saawarn S, Einstein A, Rathore A,
Mishra SD, Khade R. Oral Submucous Fibrosis: Clinical Stage,
Functional Stage, and Histopathological Grade Correlation. PJSR.
2023;16(1):9-13.
Access this article online
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DOI:
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10
People’s Journal of Scientific Research / Volume 16 / Issue 1 / Jan-June 2023
Male Female
Shankar T et al. OSMF: Clinical & Functional Stage, Histopathological Grade Correlation
study aims to evaluate the agreement and correlation
between the clinical staging, functional staging and
histopathological grading of OSMF patients.
MATERIALS & METHODS:
The present study was carried out in the
Department of Oral Pathology and Microbiology at
Bhabha College of Dental Science in Bhopal, India.
The research ethics committee of the institute
approved the study and informed consent was obtained
from each patient. The study population was composed
of patients visiting the Outpatient Department of Oral
Pathology and Microbiology. The study group
consisted of 30 individuals diagnosed with OSMF both
clinically and histopathologically. Participants were
seated comfortably in a dental chair for examination
and data was recorded using a standardized form. The
clinical examination followed the method outlined by
Kerr, Ash, and Millard. Interincisal mouth opening was
measured using a divider and scale and recorded in
millimeters. Local anesthesia was administered, an
incisional biopsy was taken from the area with
palpable fibrous bands, and the specimens were
preserved in 10% formalin for further laboratory
procedures. Post-surgical instructions were given and
sutures were placed, with cotton kept at the biopsy site.
The functional and histopathological staging
of OSMF was done according to Khanna J N and
Andrade N N. [16] Clinically subjects were grouped into
four categories, according to functional staging and
Histological staging was divided into four groups,
Group I, Group II, Group III and Group IV.
Statistical Analysis-
Following online calculators were used for statistical
analysis of the data.
Kappa (k) www.graphpad.com
Spearman's r www.gigacalculator.com
Pearson Chi -square test
www.atozmath.com
p - value
www.socscistatistics.com
RESULTS:
The present study was undertaken to assess the
correlation between clinical staging, functional
staging, and histopathological grading of patients with
OSMF. A total of 30 patients were included in the
study with an agerangebetween11-60 years, with a
mean of 36 years.
The youngest patient was 17 years old, and the only
female patient was 20 years. Most of the subjects 23
(76.6%) were in the age range of 21-50 years [Table 1].
Table 1: Distribution of cases with respect to Age and
Gender.
Age Number of
group patients
11 -20 1 1 2
Total 25 5 30 A
total of 30 patients were graded according to
functional and clinical criteria. Out of these at least in
25 patients, the functional grading was similar to the
clinical staging [Table 2]. Hence, the percentage of
agreement was 83.3%. No agreement or poor
agreement was seen in 5 cases. Overall, there was a
good agreement between clinical and functional
grading.
Out of 30 patients, only six patients presented
clinical staging similar to histopathological grading
[Table 3]. Twenty-four patients presented with no
agreement or poor agreement. Hence, the percentage
of agreement was 20%. There was a poor agreement
between clinical and histopathological grading.
There was no significant correlation between
clinical and histopathological grading.
Out of 30 patients, functional grading was
similar to histopathological staging in only 7 patients
[Table 4]. No agreement or poor agreement was seen in
23 patients. The percentage of agreement was only
23.3%. There was a poor agreement between
functional and histopathological grading.
There was no significant correlation between
functional and histopathological grading.
DISCUSSION:
The purpose of this study was to investigate
the relationship between the clinical staging,
functional grading, and histopathological grading of
patients with OSMF. 30 patients participated in the
study, 25 of whom were male and 5 were female, a
demographic that aligns with previous findings of a
higher male predilection for OSMF in the literature.
Most of the patients were of age ranging between 20 to
21 -30
7
0
7
31 -40
6
2
8
41 -50
6
2
8
51 -60
4
0
4
People’s Journal of Scientific Research / Volume 16 / Issue 1 / Jan-June 2023
11
Shankar T et al. OSMF: Clinical & Functional Stage, Histopathological Grade Correlation
Table 2: Clinical and functional staging assigned to the patients.
Functional
grading Number of
patients with
clinical stage 1
Number of
patients with
clinical stage 2
Number of
patients with
clinical stage 3
Number of
patients with
clinical stage 4
Number of
patients (%)
Stage 1
5
1
0
0
6
(20)
Stage 2
2
13
1
0
16
(53.3)
Stage 3
1
0
6
0
7
(23.3)
Stage 4
0
0
0
1
1
(3.3)
Total, n (%)
8 (26.7)
14 (46.6)
7 (23.3)
1 (3.3)
30
Test for agreement Agreement
Measure of Agreement
Weighted kappa (k) k = 0.755 ( Substantial agreement)
Correlation coefficient
Spearman’s coefficient r = 0.8 (p<0.001; significant)
Table 3: Clinical and Histopathological staging assigned to the patient.
Histopathological
Grading
Number of
patients with Number of
patients with Number of
patients with Number of
patients with
Number of
patients (%)
TEST FOR AGREEMENT AGREEMENT
Measure of agreement
Weighted kappa (k) k = -0.050 (No agreement)
Correlation coefficient
Spearman’s coefficient r =0.15 (p= 0.4662; No Correlation)
50 years, a finding that is consistent with previous
studies. All patients in the study reported a positive
history of chewing raw areca nut, which is known to be
a major cause of OSMF. The most commonly used form
of areca nut was found to be Gutkha, with 66.6 % of
patients consuming it. The use of areca nut was more
prevalent in females, while the use of Gutkha was more
prevalent in males.
Commercial freeze-dried betel quid substitutes
(such as Pan Masala, Gutkha, and Mawa), conveniently
packaged in portable sachets, have become
increasingly popular because they have a long shelf life
and do not require preparation before use. These
products contain a higher concentration of areca nut and
appear to cause oral submucous fibrosis more rapidly
than conventionally prepared betel quid[17].
clinical stage 1
clinical stage 2
clinical stage 3
clinical stage 4
Grade 1
1
2
0
0
3 (10)
Grade 2
3
2
4
0
9 (30)
Grade 3
2
5
3
1
11 (36.6)
Grade 4
2
5
0
0
7 (23.3)
Total, n (%)
8 (26.7)
14 (46.6)
7 (23.3)
1 (3.3)
30
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People’s Journal of Scientific Research / Volume 16 / Issue 1 / Jan-June 2023
Shankar T et al. OSMF: Clinical & Functional Stage, Histopathological Grade Correlation
Table 4: Functional and Histopathological Staging assigned to the patients.
Histopathological
Number of
patients
with
Number of
patients with
Functional stage
Number of
patients with
Functional stage
Number of
patients with
Functional stage
Number of
patients (%)
Functional
stage 1
2
3
4
Stage 1
1
1
1
0
3 (10)
Stage 2
3
3
3
0
9 (30)
Stage 3
3
4
3
1
11 (36.6)
Stage 4
3
3
1
0
7 (23.3)
Total, n (%)
10 (33.3)
11 (36.6)
8 (26.6)
1 (3.3)
30
Test for agreement Agreement
Measure of Agreement
Weighted kappa (k) k= -0.036 (No agreement)
Correlation coefficient
Spearman’s coefficient r = 0 (p = 0.9733; No Correlation)
All 30 patients underwent clinical staging, and
8 were classified as Stage 1, 14 as Stage 2, 7 as Stage 3,
and 1 as Stage 4. The functional staging was also done
for all patients, with 6 as Stage 1, 16 as Stage 2, 7 as
Stage 3 and 1 as Stage 4. The histopathological
examination revealed that 3 patients were included in
Grade 1, 9 in Grade 2, 11 in Grade 3 and 7 in Grade 4.
Studies by Biradar et al[18], Pandya et al[19],
Radhika et al[20], Shivakumar and Sahana[21], Goel et
al.[22]and Bhatt et al.[23]have concluded that there is a
significant correlation between the functional and
histopathological stages of OSMF, but no significant
correlation between the clinical and histopathological
stages. Our findings align with these previous studies
and suggest that clinical signs and symptoms can affect
normal functional abilities, such as mouth opening,
tongue protrusion, and cheek puffing. These
discrepancies should be evaluated to demonstrate the
functional loss to the patient and motivate them to seek
treatment.
CONCLUSION:
The objective of this study was to examine the
relationship between clinical staging, functional
staging, and histopathological grading of OSMF. We
concluded that there may be a strong correlation
between clinical and functional grading. However, the
correlation between clinical and histopathological
grading or between functional and histopathological
grading was non-significant.The strong correlation
between clinical and functional grading provides hope
that in the future, it may be possible to make predictions
about the prognosis of the disorder based on these
classifications.
Financial Support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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