Oral Submucous Fibrosis: Early Intervention with Betel Quid Chewing is Helpful


Oral submucous fibrosis is a chronic, progressive, premalignant, and irreversible condition. It is often described as a chronic, insidious, and scarring disease for the oral cavity, often with the involvement of the pharynx and the upper esophagus.1

The collagen-related disorder is characterized by inflammation, increased deposition of submucosal collagen, and formation of fibrotic bands in the oral and paraoral tissues. This condition affects any part of the oral cavity, including the pharynx.2

Oral submucous fibrosis will not improve or reverse course once it begins. It is always associated with a juxta epithelial inflammatory reaction followed by fibroelastic change of the lamina propria and epithelial atrophy, causing stiffness of the oral mucosa, trismus, and an inability to eat. This mouth dysfunction causes tissues to become rigid, and the mouth opening becomes difficult and limited. The oral tissue will appear leathery and blanched. The uvula will appear shrunken.3

Background on Oral Submucous Fibrosis

Oral submucous fibrosis dominantly affects the southern and southeastern Asian, southern African, Middle Eastern, and Indian populations. It is becoming more prevalent in Western countries due to migration.

The common cause is betel quid containing areca nut. The abnormality of this disease is multifactorial with chewing areca nuts as the primary causative agent.3 Other responsible factors play an important role in oral submucous fibrosis.

Pathogenesis contributes to a subpar repair process of inflamed oral mucosa contributing to deficient healing and scarring.4 The most common factors are commercial chewing tobacco, high intake of chilies (sensitivity to capsaicin), vitamin deficiencies (iron, folate, B-12, zinc, essential vitamins), and malnutrition resulting in low levels of serum proteins, anemia, and genetic predisposition.3,4

Areca nut increases toxic levels of copper in oral fluids by stimulating fibrogenesis through enhancing lysyl oxidase activity.4

Betel quid chewing is a tradition, custom, or ritual in many cultures. This contains tobacco and areca nut and is used in variances such as dried, fresh, sweetened, and rolled. It may be rolled in a betel leaf, which will buffer direct contact of the areca nut onto the tissue.3

The areca nut is a seed of a fruit and contains arecoline. Arecoline is the carcinogenic ingredient similar to nicotine and contributes to the histologic changes in the oral mucosa. It is also the primary psychoactive factor. This chemical stimulates the production of collagen fibers and lowers the ability of collagenase activity.4

The areca nut is very addictive and gives a sense of euphoria and well-being. It also causes a warming sensation of the body and heightens alertness. Along with being a removing agent for intestinal worms and parasites, it also aids in digestion after a meal and helps freshen the breath.3

Betel quid is often held between the teeth and inside the cheek for long periods of time.5 It is chewed and may be swallowed or spat out. If the quid is swallowed, vulnerable areas will be the back of the throat, such as the soft palate, throat, and esophagus; if spat out, the front of the mouth and lips are affected.

Oral submucous fibrosis has high morbidity and malignant transformation rates. Since this condition does not improve and only maintains or worsens, it may transform into squamous cell carcinoma. The risk may be as high as one in five people.5

Oral submucous fibrosis is seen in all ages except young children. The common age group is 20 to 40 years old. In the Asian and Indian population where this is more common, traditional betel chewing begins at a young age, resulting in some oral submucous fibrosis cases as young as 11 years of age.5

Diagnosis of oral submucous fibrosis is based on clinical signs and symptoms.3-5 With the increasing stage of the disease, quality of life is severely affected. A biopsy should be conducted to prove its diagnoses and to rule out other malignancies.

Oral Submucous Fibrosis Intraoral Symptoms

Initial Oral Submucous Fibrosis Symptoms

  • Stomatitis
  • Excessive salivation
  • Burning sensation
  • Blanching of oral mucosa
  • Blister formation
  • Presence of thin, palpable fibrous bands
  • Sparse brown/black pigmentation

Moderate Oral Submucous Fibrosis Symptoms

  • Stomatitis
  • Burning sensation
  • Dry mouth
  • Loss of taste
  • Ulceration
  • Petechiae
  • Gradual decrease in mouth opening
  • Rigid oral mucosa
  • Difficulty in blowing in/out the cheeks
  • Uvula is budlike, deviated, inverted, shrunken, or hockey stick
  • Oral mucosa blanching
  • Difficulty in whistling

Advanced Oral Submucous Fibrosis Symptoms

  • All the moderate symptoms are more severe
  • Restricted tongue movement
  • Mucosa – loss of suppleness and thick, palpable fibrous bands on buccal/labial, mottled, opaque white-marble appearance
  • Depapillation of the tongue

Oral Submucous Fibrosis Extraoral Symptoms

Initial Oral Submucous Fibrosis Symptoms

  • None

Moderate Oral Submucous Fibrosis Symptoms

  • Prominent masseter muscle
  • Nasal twang
  • Sunken cheeks and prominent malar bones
  • Thinning and stiffening lips
  • Loss of nasolabial fold
  • Swallowing difficulty
  • Mild hearing impairment
  • Hoarseness of voice
  • Weight loss

Advanced Oral Submucous Fibrosis Symptoms

  • All the moderate symptoms are more severe
  • Radiographic alteration in condylar form
  • Fibrous ankylosis of the temporomandibular joints
  • Hypertrophic and stiff masseter muscle
  • Nasal voice sound
  • Multiple folds on cheeks when attempting to open wide

Oral submucous fibrosis has clinical and functional stages (see charts below). Determining which stage a patient may have will determine what treatment should be offered.

Clinical Staging Chart

Clinical Staging Interpretation
Stage 1 Stomatitis and/or blanching of the oral mucosa
Stage 2 Presence of palpable fibrous bands in buccal mucosa and/or oropharynx with/without stomatitis
Stage 3 Presence of palpable fibrous bands in buccal mucosa and/or oropharynx, and in other parts of the oral cavity with/without stomatitis
Stage 4 Any of the above stages, along with potentially malignant disorders such as oral leukoplakia, oral erythroplakia

Any of the above stages, along with oral squamous cell carcinoma


Functional Staging Chart

Functional Staging Interpretation
M1 Staging Interincisal mouth opening 35 mm or greater
M2 Staging Interincisal mouth opening between 25 mm and 35 mm
M3 Staging Interincisal mouth opening 15 mm to 25 mm
M4 Staging Interincisal mouth opening less than 15 mm


Oral Submucous Fibrosis Treatment

Depending on the stage, progression depends on treatment management of oral submucous fibrosis.3 Since oral submucous fibrosis is not reversible, monitoring it is highly recommended. Frequent evaluation is advised for the development of oral cancer.

Cessation of habits such as betel quid chewing will minimize disease progression. Correction of nutritional deficiencies with nutritional supplements added to the diet may be recommended.

The usual treatment proposed is corticosteroid injections into the fibrotic bands every six to eight weeks. Hyaluronidase is also used to break down connective tissue.3 To maintain function while preventing further mouth opening limitations, mouth-opening exercises are helpful, and it’s a way to determine the progression of this condition.5

Surgical removal of fibrous tissue may be advised with tissue grafting as an extension.4

With there being no healing or curing of oral submucous fibrosis, noticing initial signs and symptoms is a key factor. In the United States, betel quid chewing is not prominent, but it is in certain cultures that we may treat in our offices. If it can be caught early, our profession may be able to maintain a patient’s quality of life.

Now Listen to the Today’s RDH Dental Hygiene Podcast Below:


  1. Ali, F.M., Patil, A., Patil, K., Prasant, M.C. Oral Submucous Fibrosis and Its Dermatological Relation. Indian Dermatology Online Journal. 2014; 5(3): doi:10.4103/2229-5178.137772. Retrieved from http://www.idoj.in/article.asp?issn=2229-5178;year=2014;volume=5;issue=3;spage=260;epage=265;aulast=Ali
  2. Rawson, K., Prasad, R.K., Nair, J.J. Oral Submucous Fibrosis — The Indian Scenario. Review and Report of Three Treated Cases. J Indian Acad Oral Med Radio. 2017; 29: 354-7. Retrieved from http://www.jiaomr.in/article.asp?issn=09721363;year=2017;volume=29;issue=4;spage=354;epage=357;aulast=Rawson/
  3. Rao, N.R., Villa, A., More, C.B. et al.Oral Submucous Fibrosis: A Contemporary Narrative Review with a Proposed Inter-professional Approach for an Early Diagnosis and Clinical Management. J of Otolaryngol – Head & Neck Surg. 2020; 49(3). Retrieved from https://doi.org/10.1186/s40463-020-0399-7
  4. A Digital Manual for the Early Diagnosis of Oral Neoplasia: Oral Submucous Fibrosis. World Health Organization: International Agency for Research on Cancer. Retrieved from https://screening.iarc.fr/atlasoral_list.php?cat=A5&lang=1
  5. Dyall-Smith, D. Oral Submucous Fibrosis. DermNet NZ. 2010. Retrieved from https://www.dermnetnz.org/topics/oral-submucous-fibrosis