A 5-year-old girl was reported to the outpatient department with a chief complaint of limited mouth opening for 3 months. A history of burning sensation of her mouth on taking hot and spicy food for 6 months followed by a gradual reduction in the mouth opening to the present size was given. On taking a personal history, her grandparents revealed that the girl had a habit of eating mud when she was 3 years old. Her grandparents, being chronic tobacco chewers, started giving her betel nut to make her stop eating mud. The girl eventually stopped the habit, but she replaced it with chewing areca nut.\nOn examination, the cheeks were shrunken and the mouth opening was reduced to an interincisal distance of 15 mm []. Generalized pallor and blanching were observed on either side of the buccal mucosa, upper and lower labial mucosa, and hard and soft palate [], giving a marble-like appearance. The tongue movements were restricted. On palpation, the oral mucosa was thick and leathery with difficulty in retracting the cheeks and lips. Thick fibrous bands were palpable on either side of the buccal mucosa and on the upper and lower labial mucosa.\nHematological investigations were done to rule out anemia, and a provisional diagnosis of OSMF Pindborg Stage II was given. The patient was also subjected to ultrasonographic examination, which revealed masseter muscle hypertrophy. Biopsy was not suggested considering the age of the patient and a strong evidence of the clinical diagnosis.\nThe patient and her grandparents were counseled to immediately stop the habit of areca nut and consume food which is free from chilies and spices. An initial treatment of complete oral prophylaxis was done. They were advised to use 0.1% Kenocort cream twice daily, multivitamin syrup, 5 ml of diluted tulasi water thrice daily, and physiotherapy using ice cream spatula for three to five times a day, until the patient experiences discomfort.\nWith the help of an experienced pedodontist and a prosthodontist, a mouth-exercising device was fabricated and given to the patient. The device was advised, primarily targeting an improvement in the texture, consistency, and elasticity of the buccal mucosa. Parents were trained regarding the use of that device. Follow-up is being done for every 1 month for 4 months.\nThe mouth-exercising device consisted of extraoral and intraoral acrylic plates joined together with a helical loop made up of 19 gauge wire.[] The wire was attached to the convex surface of the extraoral plate and concave surface of the intraoral plate, giving a spring action. The patient was asked to squeeze or stretch the buccal mucosa in between the two plates (larger plate extraorally and smaller plate intraorally) until she experiences discomfort. In this case, the patient was advised to exercise for a minimum of 20 min (10 min on each side) thrice daily unless she elicits discomfort or in case of any tissue injury [].\nThe patient has shown a remarkable improvement after 4 months of extensive conservative therapy with a 5 mm increase in the interincisal distance (20 mm in total). There was a slight improvement in the elasticity of the buccal mucosa. The treatment plan was continued, and the patient is under follow-up.
A girl aged 6 years reported with her mother to the Department of Oral Medicine and Radiology of a Tertiary Care Dental Hospital with the chief complaint of inability to open mouth along with a burning sensation of mucosa while taking spicy food for 6 months. The medical history was non-contributory. The patient reported a habit of chewing areca nut 3 to 4 times a day for the past 4 years. A long-standing history of chewing areca nut was present in her grandmother who infused this habit in her granddaughter not knowing the harmful effects of the same. General physical examination was non-contributory. Extraoral examination revealed a restricted mouth opening of 9 mm. Intraoral examination revealed blanching of upper and lower labial mucosa, bilateral buccal mucosa, and palate. There was depapillation of the anterior dorsal surface of the tongue (). The tongue movements were restricted and tongue protrusion was 28.52 mm. Vertically thick fibrous bands were palpable on bilateral buccal mucosa, pterygomandibular raphe, hard and soft palate. Positive history of chewing areca nut along with clinical findings led to a provisional diagnosis of OSMF.\nAn incisional biopsy was performed from the right buccal mucosa and histopathological examination showed parakeratinized stratified squamous epithelium with a short blunt to flattened rete ridges with stromal tissue composed of densely bundled collagen fibers, and juxtaepithelial hyalinization (). The overall picture was suggestive of highly advanced OSMF.\nThe patient and her mother were counseled regarding the adverse effects of chewing areca nut and the potential to cause oral cancer. The patient was advised to stop chewing areca nut. She was treated with sesame oil pulling for 5 minutes daily along with topical application of triamcinolone acetonide (0.1%) and curcumin tablet 300 mg once daily. The patient was given a sesame oil sachet and was instructed to perform oil pulling every day on an empty stomach by emptying the entire 10 mL of oil and swishing it in the mouth for at least 5 minutes without swallowing the oil. This was followed by spitting the oil and brushing the teeth. The patient was refrained from eating anything for at least 30 minutes. The patient was followed up at a regular interval of 1 month up to 6 months followed by follow-up at an interval of 3 months thereafter. She has stopped chewing areca nuts and showed improvement in symptoms. After 3 years of follow-up, the mouth opening is 22.29 mm () and tongue protrusion is 33.39 mm (). Patient is still under follow-up.