Dr. Sai Praveen: I am Dr. Sai Praveen, an Associate Professor working at Krishna Theja Dental College, Tirupati. I also have a private clinical practice, so I am currently working in both clinical practice and academia.

Dr. Sai Praveen: That's a good question. In my opinion, nowadays, people are getting tests and investigations done from home. However, even though they undergo investigations, one should always seek professional advice to receive proper treatment. While blood tests may be conducted at home, a hospital visit is still necessary for a comprehensive check-up and treatment plan. Coming to dentistry, there is an increasing awareness among people about treatment options. Nowadays, most patients coming to our clinic inquire about lasers, painless procedures, and tooth-colored materials. In the past, they would ask about fillings or cement in layman's terms. While awareness has increased, as you mentioned, there are still people who remain unaware.

Dr. Sai Praveen: Many people in India are unaware of the importance of dental health, which is why they end up losing teeth. If this continues, it can lead to reduced appetite and dietary intake, which may further deteriorate their overall health. As people age, changes in dietary habits affect their health, and in such cases, tooth loss becomes a problem. Without teeth, they cannot consume fresh fruits and vegetables and must rely on a soft diet, which can further impact their health. Even consuming juices may lead to increased cholesterol levels or elevated blood sugar in diabetic patients.

Therefore, regular dental check-ups are crucial. While awareness is improving, it still needs significant enhancement. People often think dentistry is only about teeth, but my specialty, Oral Medicine and Radiology, focuses on both teeth and the oral mucosa. The soft tissue of the oral cavity is an integral part of the dental field, and as a specialist, I examine both teeth and surrounding soft tissues.

Dr. Sai Praveen: It is said that twice a year is always advisable. Regular check-ups every six months help remove debris accumulation and maintain oral health.

Dr. Sai Praveen: No, it was a planned decision. My primary interest has always been in Oral Medicine and Radiology. This field serves as a bridge between dentistry and medicine. The mouth is often considered a mirror of systemic diseases. If a patient has systemic health issues, such as heart or kidney problems, there may be manifestations in the oral cavity. For example, fluid accumulation in the face can indicate kidney issues, while swelling in the legs can signal heart problems. Similarly, diabetes can lead to increased gum bleeding and delayed wound healing in the mouth. Many systemic diseases present oral manifestations that help guide treatment plans.

Radiology is also a crucial aspect of my specialty. For instance, when patients require implant therapy, we analyze high-resolution images like CBCT (Cone Beam Computed Tomography), a top-end imaging modality in dentistry. We interpret these images to determine implant placement and dimensions. Additionally, we assess oral manifestations of systemic disorders and help advise proper treatment plans. Some skin lesions also appear in the oral cavity, and these cases are managed by oral medicine and radiology specialists. Moreover, we play a role in diagnosing whether a condition is cancerous or has the potential to become malignant. These are the three key aspects of my field.

Dr. Sai Praveen: In the present scenario, potentially malignant disorders need attention because they exist in a transitional state between normalcy and malignancy. It is important to identify them early and manage them effectively.

Dr. Sai Praveen: Potentially malignant means it is something that is above normal and below malignancy. It is not malignant, but it can change into a malignant one. It has the ability to change into cancer. So, that's the reason why we call it potentially malignant. There are many such conditions that are potentially malignant conditions like oral submucous fibrosis, leukoplakia, Lichen Planus, erythroplakia, etc. All these conditions are potentially malignant. They have the ability to change into cancer and progress to malignancy.

Dr. Sai Praveen: Oral submucous fibrosis condition is mainly because of Areca nut (Betel Palm/ Betel Nuts/ Indian Nuts) chewing, and it is characterized by limited mouth opening. One can notice a limited or restricted mouth opening.

The above picture is one of my patients. In the picture, you can notice a reduction in mouth opening. So, oral submucous fibrosis is a potentially malignant disorder that can transfer into cancer, and it is mainly characterized by this restricted mouth opening and also characterized by burning sensation upon taking hot and spicy foods. This is the main characteristic feature which makes one suspect of Oral Submucous Fibrosis.

Dr. Sai Praveen: According to progression, this is mainly because of Areca nut. In a few cultures, they will be taking it as a devotional thing or a habituation among families. If they chronically take it for around 5 to 10 years. Within a span of 5 to 10 years, people first develop the burning sensation of the disease. So, first they will feel a burning sensation upon taking hot and spicy foods and in the later stages, they can observe whitish discoloration of the oral mucosa. 

In the above picture, you can see the change in mucosal color. Usually, oral mucosa is coral pink in color, but here in this picture, you can see it is a bit dry, and has a marble white like appearance. This is the next stage to burning sensation.

First there will be a burning sensation to hot and spicy foods. If we still neglect it, there will be white marble to white discoloration of the mucosa. If one still neglect it, one can palpate fibrous bands within the oral mucosa, and one can notice that. These fibrous bands are spread all over the buccal mucosa, on the lips, and they also restrict the tongue movements. Continuing the habit, one can notice thickening of cheeks. The cheeks become very thick, and you cannot blow or puff your cheeks. Next, followed by loss of mouth opening, or restricted mouth opening. Usually it is said that people can put their three fingers into the oral cavity. The mouth can be open until they can fix their three fingers in between the teeth, so that dimension will be reduced. This limits the food intake of the subject also.

Dr. Sai Praveen: Genetics play a role, but still, the role of genetics is very unclear in this condition, because most people say this could be because of HLA, the human leukocyte antigen gene and the role of HLA gene here is still unclear, and the research is going on. Coming to the environmental factors, it is said that globally, India is the house for this oral submucous fibrosis, because in India we are getting a lot of products like Pan masala, Zarda and most of the subjects are reported from India only. One can clearly understand that, based upon genetic conditions, they have very few studies, but considering environmental factors, it is more distributed to our region.

Dr. Sai Praveen: It affects the quality of the patient, because the patient's quality of life first depends upon the quality of the food they take, if there is restricted diet or loss of appetite in such situations, the patient feels dizzy or one loses their quality of life. He cannot enjoy whatever food he wants to eat, and cannot even depend upon hot tea or hot coffee, and cannot go with any type of spices. This condition restricts intake of the food that he desires.

Moreover, this also restricts patients' ability to have deep bites. There is restricted mouth opening, one cannot brush their teeth properly. So there will be halitosis or bad breath from the mouth. I think you can get it if there is any bad breath from the mouth, there will be social rejection, which imbalances the person's life. Quality of life is deployed both in terms of enjoying his food, and also having social contacts and his inability to pronounce some words. See, like few words can be pronounced only if you can move your tongue freely. As there is restricted tongue movements, one cannot even treat properly in such conditions. So these conditions will cause imbalance in his social life.

Dr. Sai Praveen: No, it is associated with areca nut chewing alone. It is said that the female set of population tend to use this areca nut chewing most frequently. The main progression or main occurrence depends upon the Areca nut and is mostly commonly seen in the female population and the common age group usually starts from 40 to 50 years, especially in their the fourth and fifth decades of life. It is very rare to see in the third decade, like in the 30s.

Dr. Sai Praveen: Once on taking Areca nut, the products of Areca nut should be absorbed into the oral mucosa. When they are being absorbed, they stimulate the collagen formation, and also prevent the lysis or breakdown of the produced collagen. So, all these changes, like the formation of excess collagen and stopping of collagen fibers break down take around 10 years. Estimating that a person began these habits at age 20, their progression and identification typically occur around 40 to 50 years later. So roughly we can calculate and that could be the predilection for the age.

Dr. Sai Praveen: The first thing is we can diagnose the condition by palpation of fibrous bands. If we can palpate the fibrous bands and confirm the history of areca nut chewing, then we can diagnose this condition.

To have some evidence-based diagnosis, we can go with a biopsy. We can take a specimen of a piece of tissue, and we can send it for histopathological analysis, where we can see all changes, like alteration of normalcy and these changes can be suggested to oral submucous fibrosis.

Alteration of normalcy includes inflammatory changes beneath the epithelium, and above the inflammatory changes, we can see deposition of fibrous bands, and alteration of nuclear cytoplasmic ratio in the above epithelial cells. The histopathological changes will diagnose this condition.

VELscope is a light-based diagnostic technique, it is not an advanced one. It is an age-old technique, but one can use it also for identifying. So these are all the three things. We can go with palpation of fibrous bands along with the history, histopathology, and also technique like light-based diagnostics. Coming to reversibility, it is not exactly reversible. We can restrict the progression, as I said earlier. We can restrict it as potentially malignant, and we can stop it going into malignant condition or cancer condition. And we can increase the mouth opening by around 3 to 4 mm.

Dr. Sai Praveen: It's just a pre-management condition. It's not cancer, if you leave it as such. Without any treatment, it will rapidly progress into cancer. It has a 17% chance of progressing into cancer.

Firstly, it will cause some ulcerations within the oral cavity, and they usually tend to bleed readily, and supra added candidal infection is very common in such conditions, so which will further infect or affect the gastrointestinal system, as food enters through the oral cavity. All the microbiota that has accumulated because of improper cleaning inside the oral cavity will also go inside our gastrointestinal tract. All these will further deteriorate our systemic health. Also, if we don't treat it, it will progress into cancer. Moreover, we can also appreciate small ulcers in the oral cavity, which are further supra infected by Candida, and they have every chance to go inside along with the food, and they also damage our gastrointestinal tract.