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          "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">&#40;A&#41; Oral mucosa biopsy specimen showing hyalinization and fibrosis of the submucosa with a mild submucosal inflammatory infiltrate &#40;hematoxylin&#8211;eosin&#44; original magnification &#215;40&#41;&#46; &#40;B&#41; Epithelial atrophy without dysplasia and mild hyperkeratosis&#46; Scattered mononuclear cell infiltration and pigment incontinence in the submucosa &#40;hematoxylin&#8211;eosin&#44; original magnification &#215;200&#41;&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Oral submucous fibrosis &#40;OSMF&#41; is a chronic&#44; insidious&#44; premalignant condition characterized by inflammation and progressive fibrosis of the oral mucosa that results in narrowing of the oral opening&#46; It is strongly associated with areca nut chewing&#44; a frequent habit in Southeastern Asia&#46; Reports of OSMF in the European continent have been exceptional to date&#46; However&#44; due to immigration from endemic areas&#44; an increasing incidence of this disease is expected&#46; We report a recently diagnosed case at our department&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">A 60-year-old woman&#44; a native of Bangladesh&#44; presented with a 24-month history of progressive limitation in mouth opening and oral pain during food intake&#46; Her past medical history was unremarkable&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Physical examination revealed a diffuse paleness and hardening of the oral mucosa&#46; Whitish reticular pigmentation of the alveolar and labial mucosa was also observed&#46; The patient presented trismus&#44; difficulty with tongue protrusion&#44; and limited vertical mouth opening&#59; the distance between the superior and inferior central incisor edges was 18<span class="elsevierStyleHsp" style=""></span>mm &#40;average&#44; 40<span class="elsevierStyleHsp" style=""></span>mm&#41;&#46; On palpation&#44; symmetrical fibrous bands in the oral mucosa were also noticed &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; Blood tests revealed mild iron deficiency anemia and immunologic tests were negative for antinuclear antibodies&#46; Hepatitis C and anti-HBc antigen tests were negative&#46; A punch biopsy for histopathologic study was performed&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Hematoxylin and eosin sections showed a slightly hyperkeratotic atrophic mucosa and diffuse hyalinization of the subepithelial stroma&#46; A discrete lymphoid interstitial inflammatory infiltrate with pigment incontinence was present in the upper submucosa&#46; Concentric fibrotic layers surrounding mucous glands and blood vessels were also noted&#46; A direct immunofluorescence study was negative &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">The findings were suggestive of OSMF&#46; We asked the patient if she chewed areca nut and she admitted having done so many times a day for the past 20 years&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The patient was started on oral glucocorticoids &#40;prednisone 0&#46;5<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;d for 3 weeks with progressive dose tapering and pentoxifylline 400<span class="elsevierStyleHsp" style=""></span>mg&#44; 3 times a day&#41;&#44; and was strongly advised to stop chewing areca nuts&#46; Subjective clinical improvement&#44; with decreasing symptoms&#44; was observed after 3 months&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">OSMF is rare in Spain&#46; The most common cause is the chewing of areca nuts&#44; either alone or in association with other substances such as tobacco&#44; spices&#44; or lime wrapped in a betel leaf&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">1&#44;2</span></a> Habitual long term chewing leads to nonreversible fibrosis of the oral mucosa&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">The clinical manifestations usually appear within 2&#8211;5 years of starting the chewing habit&#46; The most common clinical presentation is limited mouth opening&#44; followed by a burning sensation&#46; Pain or tongue protrusion difficulties may also be reported by some patients&#46; Mucosal blanching and palpable fibrous bands are the most common findings in the physical examination&#46; Others include shrunken uvula&#44; depapillated tongue&#44; and ulceration&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">3</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Histopathological features include a combination of mucosal and submucosal changes&#46; Atrophic changes such as thinning of the epithelium&#44; liquefaction degeneration&#44; and pigment incontinence are usually present&#46; Dysplasia may be observed in up to 8&#46;6&#37; of cases&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">4</span></a> Submucosal findings are characterized by almost constant stromal fibrosis and hyalinization associated with a diffuse discrete chronic mononuclear inflammatory infiltrate&#46; Patients with OSMF have an increased risk of squamous cell carcinoma&#44; which may develop in about 2&#46;3&#8211;7&#46;6&#37; of cases&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">5</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">The pathogenesis of OSMF has not been fully elucidated&#44; although mechanisms such as arecoline hydrolysis have been postulated&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">The differential diagnosis should include certain temporomandibular joint disorders &#40;ankylosis&#41;&#44; physical damage to the oral mucosa &#40;induced&#44; for example&#44; by radiotherapy or caustic ingestion&#41;&#44; autoimmune connective diseases leading to mucosal sclerotic changes &#40;scleroderma&#41;&#44; metabolic disorders &#40;amyloidosis&#41;&#44; and immunologically mediated mucocutaneous disorders &#40;lichen planus or mucous membrane pemphigoid&#41;&#46; A tissue sample may be indicated in cases of diagnostic doubt and investigations of dysplasia&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Cessation of areca chewing has been reported to stop progression and in rare cases&#44; improve the condition&#44; and should be recommended at all stages of disease&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">6</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">Several treatments have been proposed for OSMF&#44; but in most cases&#44; clear evidence of their effectiveness is lacking&#46; Oral or intralesional corticosteroids are the most widely used treatment&#46; Pentoxifylline&#44; interferon gamma&#44; and lycopene have been occasionally been used with variable results&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">7</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">Treatment seems to be useful only in the early stages of disease&#44; before the development of trismus&#46; In advanced stages&#44; management approaches focus on early detection of oral cancer and surgical procedures to restore an acceptable degree of oral opening&#46; Early recognition and diagnosis is therefore important&#46; Long-term follow-up is advisable due to the risk of malignant transformation into squamous cell carcinoma&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflict of interest</span><p id="par0075" class="elsevierStylePara elsevierViewall">The authors declare no conflict of interest&#46;</p></span></span>"
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Case and Research Letters
Progressive limitation of mouth opening
Limitación progresiva de la apertura bucal
P. García-Martínez
Autor para correspondencia
60782@parcdesalutmar.cat

Corresponding author.
, S. Segura, J.E. Herrero-Gonzalez, R.M. Pujol
Departamento de Dermatología, Hospital del Mar, Parc de Salut Mar, Institut Hospital del Mar d’Investigacions Mèdiques, Barcelona, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Oral submucous fibrosis &#40;OSMF&#41; is a chronic&#44; insidious&#44; premalignant condition characterized by inflammation and progressive fibrosis of the oral mucosa that results in narrowing of the oral opening&#46; It is strongly associated with areca nut chewing&#44; a frequent habit in Southeastern Asia&#46; Reports of OSMF in the European continent have been exceptional to date&#46; However&#44; due to immigration from endemic areas&#44; an increasing incidence of this disease is expected&#46; We report a recently diagnosed case at our department&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">A 60-year-old woman&#44; a native of Bangladesh&#44; presented with a 24-month history of progressive limitation in mouth opening and oral pain during food intake&#46; Her past medical history was unremarkable&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Physical examination revealed a diffuse paleness and hardening of the oral mucosa&#46; Whitish reticular pigmentation of the alveolar and labial mucosa was also observed&#46; The patient presented trismus&#44; difficulty with tongue protrusion&#44; and limited vertical mouth opening&#59; the distance between the superior and inferior central incisor edges was 18<span class="elsevierStyleHsp" style=""></span>mm &#40;average&#44; 40<span class="elsevierStyleHsp" style=""></span>mm&#41;&#46; On palpation&#44; symmetrical fibrous bands in the oral mucosa were also noticed &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; Blood tests revealed mild iron deficiency anemia and immunologic tests were negative for antinuclear antibodies&#46; Hepatitis C and anti-HBc antigen tests were negative&#46; A punch biopsy for histopathologic study was performed&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Hematoxylin and eosin sections showed a slightly hyperkeratotic atrophic mucosa and diffuse hyalinization of the subepithelial stroma&#46; A discrete lymphoid interstitial inflammatory infiltrate with pigment incontinence was present in the upper submucosa&#46; Concentric fibrotic layers surrounding mucous glands and blood vessels were also noted&#46; A direct immunofluorescence study was negative &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">The findings were suggestive of OSMF&#46; We asked the patient if she chewed areca nut and she admitted having done so many times a day for the past 20 years&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The patient was started on oral glucocorticoids &#40;prednisone 0&#46;5<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;d for 3 weeks with progressive dose tapering and pentoxifylline 400<span class="elsevierStyleHsp" style=""></span>mg&#44; 3 times a day&#41;&#44; and was strongly advised to stop chewing areca nuts&#46; Subjective clinical improvement&#44; with decreasing symptoms&#44; was observed after 3 months&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">OSMF is rare in Spain&#46; The most common cause is the chewing of areca nuts&#44; either alone or in association with other substances such as tobacco&#44; spices&#44; or lime wrapped in a betel leaf&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">1&#44;2</span></a> Habitual long term chewing leads to nonreversible fibrosis of the oral mucosa&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">The clinical manifestations usually appear within 2&#8211;5 years of starting the chewing habit&#46; The most common clinical presentation is limited mouth opening&#44; followed by a burning sensation&#46; Pain or tongue protrusion difficulties may also be reported by some patients&#46; Mucosal blanching and palpable fibrous bands are the most common findings in the physical examination&#46; Others include shrunken uvula&#44; depapillated tongue&#44; and ulceration&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">3</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Histopathological features include a combination of mucosal and submucosal changes&#46; Atrophic changes such as thinning of the epithelium&#44; liquefaction degeneration&#44; and pigment incontinence are usually present&#46; Dysplasia may be observed in up to 8&#46;6&#37; of cases&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">4</span></a> Submucosal findings are characterized by almost constant stromal fibrosis and hyalinization associated with a diffuse discrete chronic mononuclear inflammatory infiltrate&#46; Patients with OSMF have an increased risk of squamous cell carcinoma&#44; which may develop in about 2&#46;3&#8211;7&#46;6&#37; of cases&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">5</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">The pathogenesis of OSMF has not been fully elucidated&#44; although mechanisms such as arecoline hydrolysis have been postulated&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">The differential diagnosis should include certain temporomandibular joint disorders &#40;ankylosis&#41;&#44; physical damage to the oral mucosa &#40;induced&#44; for example&#44; by radiotherapy or caustic ingestion&#41;&#44; autoimmune connective diseases leading to mucosal sclerotic changes &#40;scleroderma&#41;&#44; metabolic disorders &#40;amyloidosis&#41;&#44; and immunologically mediated mucocutaneous disorders &#40;lichen planus or mucous membrane pemphigoid&#41;&#46; A tissue sample may be indicated in cases of diagnostic doubt and investigations of dysplasia&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Cessation of areca chewing has been reported to stop progression and in rare cases&#44; improve the condition&#44; and should be recommended at all stages of disease&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">6</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">Several treatments have been proposed for OSMF&#44; but in most cases&#44; clear evidence of their effectiveness is lacking&#46; Oral or intralesional corticosteroids are the most widely used treatment&#46; Pentoxifylline&#44; interferon gamma&#44; and lycopene have been occasionally been used with variable results&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">7</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">Treatment seems to be useful only in the early stages of disease&#44; before the development of trismus&#46; In advanced stages&#44; management approaches focus on early detection of oral cancer and surgical procedures to restore an acceptable degree of oral opening&#46; Early recognition and diagnosis is therefore important&#46; Long-term follow-up is advisable due to the risk of malignant transformation into squamous cell carcinoma&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflict of interest</span><p id="par0075" class="elsevierStylePara elsevierViewall">The authors declare no conflict of interest&#46;</p></span></span>"
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ISSN: 00017310
Idioma original: Inglés
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