Prevalence of Oral Sub Mucosal Fibrosis in Pre- Anesthesia Clinic in India: A Cross Sectional Observational Study

Introduction: Oral submucous fibrosis (OSMF) is a premalignant lesion of the buccal mucosa usually caused by chewing of betel nut, areca nut and tobacco. OSMF causes difficulty in laryngoscopy and intubation of the trachea. Patient of submucosal fibrosis do come for emergency and elective surgeries requiring general anaesthesia. In such scenario maintaining airway is a big challenge for anaesthesiologist. Knowledge of Prevalence of submucosal fibrosis in local region and degree of OSMF with difficult intubation may help anaesthesiologist to prepare and plan airway management in such conditions. Aims and Objectives: To evaluate the prevalence of oral submucous fibrosis in patients coming in pre-anaesthesia clinic and assessment of airway and prevalence of degree of OSMF by measuring Interincisal mouth opening in patients of oral submucosal fibrosis. Methods: Cross-sectional observational study was conducted in the department of anaesthesiology on 500 patients coming in pre-anaesthesia clinic. Patients were identified and sent Original Research Article Agrawal et al.; JPRI, 33(38A): 218-222, 2021; Article no.JPRI.71090 219 to dental department for confirmation of diagnosis OSMF if one or more clinical feature of OSMF were present. A detailed proforma was used to record demographic parameter, the type of tobacco, betelnut and areccanut chewing habits, difficulty in mouth opening, inter incisor distance. OSMF was divided in 4 stages on the basis of inter incisor distance. Results: Prevalence rate of submucosal fibrosis patients coming in our pre-anaesthesia clinic was 8%. Thirty patients were found to be in stage 1 (75%.), nine patients were found to be in stage 2 (22.5%) and only one patient was in stage 3. Conclusion: Being aware of the prevalence of OSMF in the region and stages of OSMF in regard to inter incisor distance in pre-operative clinic helps anaesthesiologists to prepare and plan airway management. And hence surgical exploration can be avoided.


INTRODUCTION
Oral submucous fibrosis (OSMF) is a premalignant lesion of the buccal mucosa usually caused by chewing of betel nut, areca nut and tobacco. It is characterised by the slowly progressive development of fibrous bands beneath the oral mucosa with secondary mucosal atrophy. It is widely accepted to be a collagen disease of insidious onset associated with chronic local irritation which will lead to limited opening of the oral cavity or inability to open the mouth due to which a patient can neither consume normal diet nor maintain good oral hygiene [1]. OSMF causes difficulty in laryngoscopy and intubation of the trachea. Patients with OSMF require anaesthesia for trismus correction, resection or reconstructive surgery [2] Patient of submucosal fibrosis do come for other emergency and elective surgeries requiring general anaesthesia. In such scenario maintaining airway is a big challenge for anaesthesiologist. Knowledge of prevalence of submucosal fibrosis in local region and degree of OSMF with difficult intubation may help anaesthesiologist to prepare and plan airway management in such conditions. In our crosssectional observational study, we assessed airway (Interincisal mouth opening) of all the patients coming for anaesthesia in our institute. We assessed the prevalence of submucosal fibrosis in patients coming in pre-anaesthesia clinic and assessing the degree of submucosal fibrosis in term of Interincisal mouth opening.

AIMS & OBJECTIVES
1) To evaluate the prevalence of oral submucous fibrosis in patients coming in preanaesthesia clinic 2) Assessment of airway and prevalence of degree of OSMF by measuring Interincisal mouth opening in patients of oral submucosal fibrosis.

OSMF was Divided in Following Stages [3]
Stage 1: Interincisal mouth opening up to or greater than 35 mm, stomatitis, and blanching of oral mucosa.

STATISTICS
Continuous variables were expressed as mean ± SD. SPSS version 17 was used for statistical analysis.

RESULTS
There were 500 patients screened in pre anaesthesia clinic for airway assessment and clinical diagnosis of OSMF. Forty patients were found to have OSMF. Prevalence rate of submucosal fibrosis patients coming in our preanaesthesia clinic was 8%. All the 40 patients gave history of gutkha addiction.
Out of 40 OSMF patients 35 (87%) were male and 5 (12.5%) were female. According to clinical staging OSMF was divided in 4 stages. Thirty patients were found to be in stage 1 (75%.), nine patients were found to be in stage 2 (22.5%) and only one patient was in stage 3. as shown in Table 1.

DISCUSSION
Maintaining patent airway is essential for adequate oxygenation and ventilation. Failure to do so, even for a brief period of time, can be life threatening. Patients with restricted mouth opening like patients with OSMF pose challenges for conventional, nasal or oral intubation [4]. Submental intubation and tracheostomy demand a surgical exploration with morbidities associated with them which may not be acceptable to the patient [4]. Recognition of potential for a difficult airway in pre anaesthesia clinic, measurement of interincisal distance and staging of OSMF helps anaesthesiologist to anticipate the difficulty of intubation and allows time for optimal preparation, proper selection of equipment and technique and participation of personnel experienced in difficult airway management [5]. In our study we evaluated 500 patients who visited to our pre-anaesthesia clinic. Out of this we found that 40 (8%) patients were having OSMF while Vishnudas dinesh prabhu et al had found the prevalence of oral submucous fibrosis was 1.96% at Bagalkot district [10]. We found that maximum patients of OSMF belonged to stage 1 and 2 that means inter incisor mouth opening distance more than 25 mm. Only one patient belonged to stage 3. Amit Shah et al. [5] did a study on 20 oral submucous fibrosis patients having inter incisor distance  [6,7]. In previous studies from India, a relation between gutkha, tobacco, areccanut and pan masala habits was observed with occurrence of OSMF [8][9] Similarly, we also found that all the patients of OSMF had history of such habits [10][11][12][13][14][15].

CONCLUSIONS
Being aware of the prevalence of OSMF in the region and stages of OSMF in regard to inter incisor distance in pre-operative clinic helps anaesthesiologists to prepare and plan airway management. And hence surgical exploration can be avoided. We need to increase our data base in order to be sure about the prevalence figures.

ETHICAL APPROVAL
Ethical clearance was obtained from the Institutional ethical committee.

CONSENT
As per international standard or university standard, patient's written consent has been collected and preserved by the author(s).