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.
In 2011, another 10-year-old Indian Muslim boy who had not been attending school at all was referred to the Oral Medicine Clinic, CSM Medical University, Lucknow, India by Public Health Dentist during the “Community oral health screening program”, with a complaint of reduced mouth opening, discomfort and a burning sensation particularly when eating spicy foods.\nPatient showed history of areca nut chewing since six year; the reduced mouth opening was noticed from past eight month, with discomfort and a burning sensation particularly when eating hot and spicy foods and loss of gustatory sensation.\nClinical examination of soft tissue of oral cavity reveals blanched or opaque appearance of mucosa, reduced mobility of the soft palate and tongue, loss of tongue papillae and dryness of the mouth.\nDental examination reveals dental fluorosis in the anterior teeth, carious lesion in posterior tooth and a poor oral hygiene.\nPhysical examination reveals mouth opening is 13 mm, with presence of palpable fibrous band especially in the retro molar area but does not involve the uvula and tonsil.