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ORIGINAL ARTICLE
Year : 2015  |  Volume : 6  |  Issue : 4  |  Page : 220-224

Morphometric evaluation and comparison of soft palate in individuals with and without oral submucous fibrosis: A digital cephalometric study


Department of Oral Medicine and Radiology, KLE VK Institute of Dental Sciences, KLE University, Belgaum, Karnataka, India

Date of Web Publication23-Nov-2015

Correspondence Address:
Radha Anil Deshmukh
Department of Oral Medicine and Radiology, KLE VK Institute of Dental Sciences, KLE University, Belgaum - 590 010, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0976-433X.170245

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  Abstract 

Objectives: Oral submucous fibrosis (OSMF) is one of the most common premalignant conditions affecting the oral cavity of people consuming arecanut and gutka. According to the available literature, as the disease progresses the morphology of the soft palate changes. So, the objective of present study was to evaluate and compare the morphology of soft palate in individuals with and without OSMF, using digital lateral cephalogram. Materials and Methods: Sixty male individuals were selected and divided into three groups, Group I-20 individuals (habit group), Group II-20 individuals (OSMF group), and Group III-20 individuals (individuals with no habit and/or OSMF group). The morphology of soft palate was assessed using digital lateral cephalogram. Statistical analysis was carried out using Scheffe multiple comparison test. Results: The superoinferior dimension of soft palate was increased with statistically significant difference in the habit and OSMF groups. The anteroposterior dimension was reduced in the habit group as compared to normal individuals, with statistically significant difference in the OSMF group. The type of soft palate more common in normal individuals and habit group was type 1 and 2, while type 6 was seen more commonly in OSMF group. Conclusion: Cephalometry can be efficiently used to assess the morphology of soft palate and the morphology of soft palate is altered in individuals with the habit even before the development of OSMF. So, cephalometry can be beneficial in assessing fibrosis in individuals with the habit at an early stage, which can further help in prognosis.

Keywords: Cephalometry, oral submucous fibrosis, soft palate


How to cite this article:
Deshmukh RA, Bagewadi AS. Morphometric evaluation and comparison of soft palate in individuals with and without oral submucous fibrosis: A digital cephalometric study. SRM J Res Dent Sci 2015;6:220-4

How to cite this URL:
Deshmukh RA, Bagewadi AS. Morphometric evaluation and comparison of soft palate in individuals with and without oral submucous fibrosis: A digital cephalometric study. SRM J Res Dent Sci [serial online] 2015 [cited 2022 Aug 13];6:220-4. Available from: https://www.srmjrds.in/text.asp?2015/6/4/220/170245


  Introduction Top


Oral submucous fibrosis (OSMF) is a highly potent and one of the most common premalignant conditions affecting the oral cavity of people consuming arecanut and gutka. [1] It is a chronic, progressive, scarring disease that predominantly affects the people of South-East Asian origin, including the Indian subcontinent. [2] Indian studies conducted in the year 2002 indicates that over 5 million people in India, that is about 0.5% of Indian population suffer from OSMF. In addition, due to an upsurge in the popularity of commercially prepared arecanut preparations (pan masala) and increase in use of arecanut among youngsters in Asian continents, the incidence of OSMF is most likely to be higher than what is noted in the published literature. [3],[4]

The clinical presentation of OSMF depends on the stage of the disease during detection and is characterized by juxta-epithelial inflammatory reaction and progressive fibrosis of the submucosal tissues that affects most parts of the oral cavity, including soft palate (also known as velum or muscular palate), pharynx, and upper third of the oesophagus. [5] According to the literature, as the disease progresses, the morphology of the soft palate changes.

OSMF is multifactorial in origin, and possible etiological factors include capsaicin in chillies, iron, zinc and other essential vitamin deficiencies. [6] Various autoantibodies and specific human leucocyte antigens in some patients have indicated an autoimmune role as well as a genetic predisposition for the disease. [5] However, various epidemiological studies, large cross-sectional surveys, case-contol studies, cohort and intervention studies have provided overwhelming evidence that arecanut is the main etiological factor in OSMF. [6]

Cephalometric analysis is one of the most commonly accepted techniques for evaluating the various shapes of soft palate that presents in six different forms in both normal individuals and in those with cleft lip and palate. [7] Lateral cephalogram is less expensive, more useful, easily achieved with reduced radiation, and correlates with other investigation such as computed tomography. So, it can be used for morphometric evaluation of soft palate and its surrounding structures. [8]

According to the available literature, the morphology of soft palate is altered in OSMF patients. [8],[9] An individual with habit of arecanut chewing, spicy food consumption may show changes in the morphology of soft palate. Thus, there was a need to analyze the morphology of soft palate at an early stage, that is, before the development of OSMF, which can help in initiating treatment of individual at an early stage and can also be used for counseling the individual. So, the present study was carried out to evaluate and compare the morphology of soft palate in individuals with and without OSMF, using digital lateral cephalogram.


  Materials and methods Top


The study was carried out after obtaining written informed consent from 60 male individuals selected from among the outpatients visiting the Department of Oral Medicine and Radiology.

Individuals with habit of chewing and swallowing arecanut for more than 2 times a day for at least 1-year with or without other habits like spicy food consumption, tobacco chewing, etc., were included in the study. Individuals with OSMF and individuals willing to participate in the study were included.

Individuals with reduced mouth opening due to any other reason than OSMF, individuals with cleft palate and individuals with operated cleft palate were excluded from the study.

Method of collection of data

Detailed case history, extra-oral and intra-oral examination were performed on the individuals, and 60 individuals were selected for the study based on inclusion and exclusion criteria.

These 60 male individuals were divided into three groups:

  • Group I-20 individuals (Habit group).
  • Group II-20 individuals (OSMF group) and,
  • Group III-20 individuals (individuals with no habit and/or OSMF group).


The cephalometric evaluation was carried out by only one investigator in the department and the individuals with no habit and/or OSMF were selected from individuals who need cephalogram for other reason, and the same was used for the study.

Intra-oral examination

  • The oral cavity was examined for signs of OSMF like pallor in buccal mucosa, labial mucosa and palate, shrunken or deviated uvula, burning sensation in oral cavity, etc.
  • The oral mucosa was palpated to check for fibrous bands.
  • The interincisal distance was noted between the incisal edges of maxillary central and mandibular central incisors on maximum mouth opening and OSMF patients were grouped based on LAI DR classification into A, B, C, D groups. [10]


Cephalometric evaluation of soft palate

  • Patients were positioned in cephalostat with Frankfort plane parallel to the floor. Digital lateral cephalograms were taken using KODAK 8000C System. Then the morphology of the soft palate on each lateral cephalogram was examined using DICOM software.
  • The length, that is, anteroposterior dimension of the soft palate was evaluated digitally by measuring the linear distance from the posterior nasal spine to the tip of the uvula of the resting soft palate
  • Superoinferior dimension of soft palate was measured digitally at the thickest area of soft palate [Figure 1]a and b
  • The soft palates [Figure 2] were classified based on their morphology according to You et al. as types: 1 (leaf-shaped), 2 (rat-tail shaped), 3 (butt-like), 4 (straight line), 5 (S-shaped), and 6 (crook-shaped). [8]
Figure 1: (a) Lateral cephalogram showing measurements of soft palate. (b) Magnified image of measurements of soft palate (yellow line indicating length and blue line indicating thickness of soft palate)

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Figure 2: Types of soft palate

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Statistical analysis

Data were presented as mean ± standard deviation (SD) for quantitative variables with normal distribution and significance of difference was accepted at P < 0.05. Scheffe multiple comparison test was used for statistical analysis.


  Results Top


A total of 60 male individuals participated in the study. No significant difference was identified between individuals assigned to the Group I, Group II, or Group III, with regard to age of the individuals. The individuals were in the age range of 25-48 years, with a mean age of 38.37 ± 13.365 (mean ± SD).

The anteroposterior dimension of soft palate decreased in the OSMF group as compared to the habit group and the normal individuals. Statistically significant difference in the anteroposterior dimension of soft palate was noted among the habit and OSMF groups [Table 1].
Table 1: Comparison of length, which is anteroposterior dimension of soft palate among all the three groups

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The superoinferior dimension of soft palate decreased in the tobacco group as compared to normal individuals and in the OSMF group as compared to both the habit group and the normal individuals. Statistically significant difference in the superoinferior dimension of soft palate was noted among individuals of all the three groups respectively [Table 2].
Table 2: Comparison of thickness, which is superoinferior dimension of soft palate among all the three groups

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According to the results obtained, considering all groups, type 1 [Figure 3] was the most common type of palate. In normal individuals, type 2 [Figure 4] was the most common type of palate followed by type 1 and type 3 [Figure 5] while Type 6 [Figure 6] palate was more common in OSMF individuals [Table 3].
Figure 3: Type 1 soft palate

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Figure 5: Type 3 soft palate

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Figure 6: Type 6 soft palate

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Table 3: Distribution of types of soft palate among all the three groups

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  Discussion Top


Although OSMF has a multifactorial etiology, arecanut is considered as the main etiological factor in the development of OSMF. [2],[6] Arecanut contains four main alkaloids, that is, arecoline, arecaidine, guvacine, guvacoline, of which arecoline is the main agent. Arecoline on hydrolysis produces arecaidine that has pronounced effects on fibroblasts. When fibroblasts are exposed to both arecoline and arecaidine, there is a concentration-dependent stimulation of collagen synthesis. Another concept states that increased fibrosis in OSMF can be due to reduced degradation of collagen by forming a more stable collagen structure. The large quantities of tannin present in arecanut have the ability to reduce collagen degradation by inhibiting collagenases and thus propose the basis for fibrosis as the combined effect of tannin and arecoline by reducing degradation and increasing production of collagen, respectively.

An upregulation of copper-dependent enzyme lysyl oxidase is seen in OSMF, which plays a key role in collagen synthesis and its cross linkage. As the copper content of arecanut is high, the levels of soluble copper in saliva may also rise in volunteers who chew areca quid and can cause increase in collagen synthesis. Increase in cytokines like endothelin and tumor necrosis factor (TNF-β1) has been reported in lamina propria of OSMF patients. The increase in these cytokines along with reduction in anti-fibrotic interferon-g is postulated to be due to certain external stimuli like arecanut, which further explains the pathogenesis of OSMF. [5],[6]

Literature states that arecanut chewing is also associated with polymorphism of genes coding for TNF-α, which is known to stimulate fibroblastic proliferation in vitro providing evidence for its active role for in the pathogenesis of OSMF. [5] Arecoline reduces the matrix metalloproteinases-2 secretion and increases the tissue inhibitors of matrix metalloproteinases-1 levels resulting in increased deposition of collagen in the extracellular matrix, which may play a key role in pathogenesis of OSMF. [6]

In addition to the biochemical changes associated with the use of arecanut, its continuous chewing can also lead to increased activity of the masticatory muscles, depletion of glycogen, and muscle fatigue. The reduced blood supply following fibrosis further promotes muscle fatigue and causes extensive degeneration and fibrosis in the muscles. [6]

The clinical features of OSMF initially include blanching of oral mucosa and soft palate, followed by the development of fibrous bands. Although buccal mucosa and lips may be affected at an early stage, it is thought that the soft palate and the faucial pillars are the areas to be involved first without producing any other evident signs of fibrosis in other oral mucosal sites. The fibrous bands are generally present on both sides and run vertically in the oral mucosa. The density of the fibrous deposit may vary from a slight whitish area on the soft palate causing no symptoms to a dense fibrosis causing fixation and shortening or even deviation of the uvula and soft palate. [2]

Facial growth and development can be evaluated efficiently with the use of cephalometric radiographs. Cephalometric radiographs have been used from centuries to analyze dental and skeletal anomalies as well as soft tissue structures and form. [11] It is a relatively inexpensive method and permits a good assessment of the soft tissue elements of oral cavity, including the soft palate. Morphometric assessment of the soft palate can be carried out by measuring its length and height in the median sagittal plane on lateral cephalogram. [8]

In 2003, a study was carried out to obtain normative data for cephalometric measurements of the upper airway in the local Chinese population. In this study, twenty cephalometric airway measurements were obtained. It included measurement of size of the tongue, soft palate, nasopharynx, oropharynx, hypopharynx, and relative position of the hyoid bone and valleculae. According to this study, lateral cephalograms can be efficiently used to assess morphology of soft palate. [12]

The variation in soft palate morphology was investigated by You et al. using lateral cephalogram. Six types of soft palates described in normal individuals were: Type 1: "Leaf-shape," which was lanceolate, indicated that the middle portion of the soft palate elevated to both the naso- and the oro-side. Type 2: When the soft palate showed that the anterior portion was inflated, and the free margin had an obvious coarctation, the radiographic appearance was described as having a "rat-tail shape." Type 3: A "butt-like" soft palate showed a shorter and fatter velum appearance, and the width had almost no distinct difference from the anterior portion to the free margin. Type 4 indicated that the image of the soft palate presented a "straight line shape." Type 5: The distorted soft palate presented the S-shape. Type 6 revealed a "crook" appearance of the soft palate, in which the posterior portion of the soft palate crooks anteriosuperiorly. [8]

The results of present study showed that the thickness of soft palate increased in individuals with habit as compared to normal individuals and further increased in individuals with OSMF with a statistically significant difference. The anteroposterior dimension of soft palate reduced with a statistically significant difference in individuals with OSMF as compared to individuals with the habit. The type of soft palate more common in normal individuals and in individuals with habit was type 1 and 2. Type 6 palate was seen in the OSMF group, which was consistent with the results obtained in study carried out by Shankar et al. in 2014. [9]


  Conclusion Top


Cephalometry can be efficiently used to assess the morphology of soft palate and the morphology of soft palate is altered in individuals with habit even before development of OSMF. Thickness of soft palate is affected more as compared to its length. The type of soft palate changes from type 1 and 2 to type 6, as OSMF develops.

Acknowledgments

We acknowledge the guidance provided by all the staff of Department of Oral Medicine and Radiology and the colleagues for their valuable input.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Saraswathi TR, Ranganathan K, Shanmugam S, Sowmya R, Narasimhan PD, Gunaseelan R. Prevalence of oral lesions in relation to habits: Cross-sectional study in South India. Indian J Dent Res 2006;17:121-5.  Back to cited text no. 1
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Rajendran R. Oral submucous fibrosis. J Oral Maxillofac Pathol 2003;7:1-4.  Back to cited text no. 2
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Aziz SR. Oral submucous fibrosis: Case report and review of diagnosis and treatment. J Oral Maxillofac Surg 2008;66:2386-9.  Back to cited text no. 3
    
4.
Singh M, Chaudhary AK, Pandya S, Debnath S, Singh M, Singh PA, et al. Morphometric analysis in potentially malignant head and neck lesions: Oral submucous fibrosis. Asian Pac J Cancer Prev 2010;11:257-60.  Back to cited text no. 4
    
5.
Tilakaratne WM, Klinikowski MF, Saku T, Peters TJ, Warnakulasuriya S. Oral submucous fibrosis: Review on aetiology and pathogenesis. Oral Oncol 2006;42:561-8.  Back to cited text no. 5
    
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Arakeri G, Brennan PA. Oral submucous fibrosis: An overview of the aetiology, pathogenesis, classification, and principles of management. Br J Oral Maxillofac Surg 2013;51:587-93.  Back to cited text no. 6
    
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Deepa V, David CM, Ramnarayan BK. Morphological varieties of soft palate in normal individuals, cleft palate patients and obstructive sleep apnea patients with reference to Indian population: A preliminary digital cephalometric study. World J Dent 2013;4:241-9.  Back to cited text no. 7
    
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You M, Li X, Wang H, Zhang J, Wu H, Liu Y, et al. Morphological variety of the soft palate in normal individuals: A digital cephalometric study. Dentomaxillofac Radiol 2008;37:344-9.  Back to cited text no. 8
    
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Shankar VN, Hegde K, Ashwini NS, Praveena V, Ravi Prakash SM. Morphometric evaluation of soft palate in oral submucous fibrosis - A digital cephalometric study. J Craniomaxillofac Surg 2014;42:48-52.  Back to cited text no. 9
    
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More C, Gupta S, Joshi J, Varma S. Classification system for oral submucous fibrosis. J Indian Acad Oral Med Radiol 2012;24:24-9.  Back to cited text no. 10
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Bejdová S, Krajícek V, Peterka M, Trefný P, Velemínská J. Variability in palatal shape and size in patients with bilateral complete cleft lip and palate assessed using dense surface model construction and 3D geometric morphometrics. J Craniomaxillofac Surg 2012;40:201-8.  Back to cited text no. 11
    
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Samman N, Mohammadi H, Xia J. Cephalometric norms for the upper airway in a healthy Hong Kong Chinese population. Hong Kong Med J 2003;9:25-30.  Back to cited text no. 12
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]


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