Progressive trismus and burning mouth in an areca nut chewer

§Chief complaint

Burning sensation with spicy food and progressively reduced mouth opening

§Medical & dental history

• 01Chews areca nut (gutkha) 10-12 sachets daily for 12 years
• 02No tobacco smoking
• 03Difficulty with dental treatment because of limited opening

§Clinical examination

• 01Blanched, marble-like buccal mucosa with palpable vertical fibrous bands bilaterally
• 02Maximum interincisal opening 22 mm
• 03Depapillated tongue with reduced protrusion; shrunken uvula
• 04No ulceration or discrete white patch; no lymphadenopathy

§ figuresFigures (1)

Verified open-access images only, reproduced for education under their stated licences · no AI-generated or illustrative artwork · Oral Submucous Fibrosis figures pending faculty review.

§Differential diagnosis

§Final diagnosis

Oral submucous fibrosis, clinical stage III (trismus with functional limitation)

Palpable fibrous bands with mucosal blanching and progressive trismus in a chronic areca nut user is clinically diagnostic; biopsy confirms juxta-epithelial hyalinisation and assesses for coexisting dysplasia, the key malignancy concern.

§Investigations

• 01Incisional biopsy of buccal mucosa — grading of fibrosis and exclusion of dysplasia
• 02Haemoglobin and haematinics — anaemia is common and worsens mucosal atrophy
• 03Serial measurement of mouth opening and photographs

§Radiology

• 01No specific radiographic findings; OPG to assess dental status before treatment

§Treatment plan

• 01Absolute cessation of areca nut and any tobacco product with counselling
• 02Nutritional support: iron, B-complex, antioxidants
• 03Intralesional corticosteroid and hyaluronidase injections
• 04Active physiotherapy with mouth-opening exercises and devices
• 05Surgical band release with coronoidectomy and grafting for severe refractory trismus
• 06Lifelong surveillance for malignant transformation

§Surgical procedure

• 01Intralesional triamcinolone with hyaluronidase weekly for 6 weeks combined with physiotherapy

§Histopathology report

Atrophic epithelium with juxta-epithelial hyalinisation, dense collagen bundles replacing the lamina propria, reduced vascularity and a sparse chronic inflammatory infiltrate. No epithelial dysplasia identified.

§Follow-up & outcome

• 016 weeks — opening improved from 22 mm to 29 mm; burning resolved
• 026 months — opening 33 mm, habit stopped
• 03Annual review for malignant transformation, lifelong

Outcome: Functional improvement and symptom relief with habit cessation and conservative therapy; surgery avoided.

§Discussion

• 01Areca nut arecoline drives fibroblast proliferation and collagen cross-linking while reducing collagen degradation.
• 02Malignant transformation is reported in 7-13% of cases, so OSMF is a potentially malignant disorder requiring lifelong follow-up.
• 03Fibrosis does not reverse — treatment aims to arrest progression and improve function.

§Clinical pearls / learning points

• 01Palpate for bands — blanching alone can be missed in dark mucosa.
• 02Cessation is the only intervention that alters the disease trajectory.
• 03Trismus makes future oral cancer detection harder, which compounds the risk.

§Viva questions

§MCQs

§Related diseases

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