Efficacy of Oil Pulling in the Management of Oral Submucous Fibrosis: A Preliminary Study

ABSTRACT Objective: To evaluate the effectiveness of oil pulling in the management of oral submucous fibrosis (OSMF). Material and Methods: A total of 62 patients clinically and histopathologically diagnosed as OSMF were incorporated in the present study. The subjects are randomly divided equally into two groups, Group A (oil pulling group) and Group B (placebo group). Subjects in Group A were asked to perform OP with sesame oil on an empty stomach in the morning for 3 months and Group B was given placebo capsules for 3 months. Assessment of various clinical parameters was done regularly, and data were analyzed using the Chi-square test. Results: Eighty-two percent had a habit of betel nut chewing, while 18% of the patients had tobacco chewing habits, which were among the main causative factors for OSMF. Clinical improvements in mouth opening, tongue protrusion, difficulty in speech and deglutition, and burning sensation were significant in the Group A. None of the patients reported any discomfort or side effects. The symptoms were not severe in nature and resolved in few days without stopping the therapy. Conclusion: Oil pulling can bring about significant clinical improvements in the symptoms like a mouth opening and tongue protrusion.

Alteration in Serum Lipid Profile Pattern in Oral Squamous Cell Carcinoma and Potentially Malignant Disorders

ABSTRACT Objective: To evaluate and compare lipid profile level in oral submucous fibrosis (OSMF), oral leukoplakia (OL) and oral squamous cell carcinoma (OSCC) patients. Material and Methods: Thirty histopathologically diagnosed subjects each of OL, OSMF, OSCC were recruited along with 30 healthy controls. 5ml of venous blood is collected and estimated using standard diagnostic kits. Results: The mean of Total cholesterol level in controls was 219.03 mg%, in OSCC, OL and OSMF was 142.89 ± 10.21mg%, 155.44 ± 17.63 mg% and 180.60 ± 13.25 mg%, respectively. The mean low-density lipid level in controls was 137.24 mg and in OSCC, OL and OSMF groups were 109.28 ± 2.16 mg%, 126.63 ± 0.85 mg% and 119.15 ± 0.93 mg%, respectively. The mean of high-density lipid level in controls, OSCC, OL and OSMF was 42.87 ± 0.42 mg%, 36.50 ± 2.31 mg%, 21.13 ± 0.77 mg% and 28.37 ± 1.11mg%, respectively. The mean of very low density lipids level in controls, OSCC, OL and OSMF was 30.12 ± 1.51 mg%, 17.24 ± 0.80 mg%, 22.25 ± 0.93 mg% and 25.89 ± 0.43 mg%, respectively. The mean triglyceride level in controls, OSCC, OL and OSMF was 118.80 ± 9.47 mg%, 91.2 ± 3.03 mg%, 105.05 ± 2.96 mg% and 106.19 ± 3.09 mg%, respectively. Conclusion: Lipid profile levels could be early indicators of precancer and cancer.

Expression profile of salivary micro RNA-21 and 31 in oral potentially malignant disorders

Abstract Oral potentially malignant disorders (OPMD) possess significant chances of malignancy conversion. In order to develop an early diagnostic tool, the present study evaluated the expression of miRNA-21 and 31 as salivary markers. The case-control study was carried out in 36 healthy participants as controls and in 36 patients who were newly diagnosed as OPMD having four different lesions including leucoplakia, oral sub mucous fibrosis (OSMF)궱, oral lichen planus, and (OSMF)궱 with leucoplakia. The samples were also classified as non-dysplastic, or with mild, moderate, and severe dysplasia according to their histopathological reports. The salivary miRNA-21 and 31 expressions were studied using real-time PCR. The statistical analysis was carried out using SPSS version 22. Salivary miRNA-21 (p-value = 0.02) and 31 (p-value = 0.01) were significantly upregulated in severe dysplasia compared with control. Among the different lesions, leucoplakia had significant upregulation of miRNA-21 and 31. miRNA-21 can be used as a diagnostic marker with specificity of 66% and sensitivity of 69%. The area under the ROC curve was 0.820 for miRNA-21 and 0.5 for miRNA-31, which proved that miRNA-21 is a better diagnostic marker than miRNA-31 for OPMD.

Oral Candidal Carriage Among Patients with Oral Potential Malignant Disorders: A Case-Control Study

Objective: To determine the prevalence of Candida species in the saliva of patients with clinically suspected oral potentially malignant disorders (OPMD) and healthy cohorts. Material and Methods: Unstimulated saliva was collected from patients with OPMD (n=100) and age and sex matched healthy subjects (n=170). The samples were inoculated onto Sabouraud Dextrose Agar and incubated for a week. The colonies of the isolates were enumerated using a colony counter. The isolates were identified using standard phenotypic methods. The significance of oral candidal carriage was calculated using Independent T test. Odds and Risk ratio was calculated using Pearson's Chi-square test. Results: Oral candida carriage was present in 51% of patients with OPMD while healthy cohorts had a prevalence of 20.6%. A good statistical significance was observed for the prevalence of oral candidal carriage for patients with OPMD in comparison to healthy cohorts (p=0.013). Significant Odds and risk ratio was observed for the prevalence of Candida species among OPMD. Majority of the isolates in both groups were C. albicans. Colony forming units were high among patients with OPMD. Conclusion: A significant association of oral candidal carriage to oral potentially malignant disorders in comparison to healthy cohorts was observed. Candidal species may be potent risk factor for transition of OPMD to oral Squamous Cell Carcinoma.

Does Oral Submucous Fibrosis Affect the Hearing Ability of an Individual? A Cross-Sectional Study in North Indian Population

Abstract Objective: To evaluate the hearing efficiency of Oral Submucous Fibrosis (OSF) patients using Pure Tone Audiometry (PTA) and to correlate between the hearing efficiency and clinical stage of OSF. Material and Methods: Twenty-five patients clinically diagnosed as OSF were evaluated for hearing loss using 'PTA'. Patients were grouped as mild cases and severe cases. Mild cases comprised of Group A and B, and severe cases comprised of Group C and D. Patients suffering from the previous hearing were excluded from the study. The data were submitted to statistical evaluation using the Chi-square test. The level of significance was set at 5% Results: Out of the total patients, 52.4% were diagnosed as mild cases (Group M) OSF and 47.6% as severe cases (Group S). The analysis of the data of mild cases and severe cases revealed a significant association between advancing stages of OSF and hearing loss (p = 0.026). The cases in Group M after otoscopic evaluation demonstrated no visible ear defect. However, 30% of cases in Group S showed retraction of the tympanic membrane Conclusion: The results indicate an association between stages of OSF and hearing loss. With advancing stages of OSF, there may be involvement of muscles of soft palate namely the levator veli palatine or tensor veli palatine, which may lead to the narrowing of the Eustachian tube leading to a decrease in air conduction demonstrating it as hearing loss of varying degrees depending upon the involvement.

Comparative Study of the Efficacy of Newer Antioxitands Lycopene and Oxitard in the Treatment of Oral Submucous Fibrosis

Objective: To compare the efficacy of oxitard and lycopene in the management of Oral Submucous Fibrosis (OSMF). Material and Methods: 120 subjects with clinicpathologically diagnosed OSMF were included in the study and divided equally in 2 groups, Group A (oxitard) and Group B (lycopene). Group A was administered 2 oxitard capsules twice daily and Group B was given 8 mg lycopene in 2 divided doses of 4 mg for 3 months. Gingival index and plaque index were documented for all patients and compared. Evaluation for different clinical parameters was done at regular intervals and data was analyzed using the Student's paired t test and Chi-square test. P-value <0.001 was considered to be statistically significant. Results: Clinical improvements in mouth opening and tongue protrusion was significant in Group A (p<0.001). Subjective symptoms of pain associated with the lesion (p=0.0001), difficulty in swallowing (p=0.0004) and speech (p=0.0002) significantly improved in the Group A. However, there was no significant improvement in burning sensation (p>0.001) among the 2 groups. Although the mean gingival index and plaque index in group A was reduced but it was found to be not statistically significant. Conclusion: Oxitard capsules can bring about significant clinical improvements in the symptoms like mouth opening, tongue protrusion, difficulty in swallowing and speech and pain associated with the lesion when compared to lycopene, thereby improving the quality of life of the affected individuals.

Proliferative and morphologic characterization of buccal mucosal fibroblasts in areca nut chewers: A cell culture study.

Objective: To isolate, culture and characterize fibroblasts from the buccal mucosa of areca nut chewers with and without oral submucous fibrosis (OSF). Materials and Methods: Primary fibroblast cultures were established by the collagenase disaggregation technique and the phenotypic and growth characteristics were studied. Results: Cells cultured from OSF showed a statistically significant increase in both the post-mitotic fibroblast subpopulation and the population doubling time when compared with controls. Conclusion: There was a significant increase in the pro-fibrotic, post-mitotic subpopulation of fibroblasts in areca nut chewers with OSF.

Verrucous carcinoma in association with oral submucous fibrosis.

Oral verrucous carcinoma is a form of well differentiated squamous cell carcinoma characterized by exophytic over growth. It is slow growing and locally invasive tumor occurring in 6 th and 7 th decade of life. Smoking and chewing tobacco is found to be the most common etiological factor of verrucous carcinoma although oral leukoplakia may act as a predisposing factor. This is a rare case of oral varrucous Carcinoma seen in association with oral submucous fibrosis in a younger patient with long standing history of chewing tobacco.

Evaluation of oral submucous fibrosis using ultrasonographic technique: A new diagnostic tool.

Aim: The aim of this study is to evaluate oral submucous fibrosis (OSMF) by clinical and histopathological examination, and compare the results with those from ultrasonographic technique. Materials and Methods: 30 clinically diagnosed OSMF patients were subjected to both ultrasonographic and histopathological evaluation before treatment. Later, only ultrasonographical examination was done during 4 th and 8 th week of treatment. Prognosis of the lesion for the treatment was evaluated. Peak systolic velocity (PSV) of blood in the lesional area was statistically analyzed. 10 normal individuals without any mucosal lesions were considered as the control group. Results: In normal individuals, ultrasonography delineates normal mucosa with uniform fine mottled appearance with interspersed hypoechoic areas. Color Doppler and spectral Doppler depicts uniform distribution of blood vessels and normal peak systolic velocity of blood respectively. All OSMF patients were diagnosed upon clinical and histopathological examination. Clinical examination revealed 14 individuals with unilateral palpable fibrotic bands and 16 individuals with bilateral fibrotic bands whereas, ultrasonographic evaluation revealed 6 individuals with unilateral fibrotic bands and 24 individuals were with bilateral fibrotic bands, which was statistically significant. Ultrasonography demonstrated number, length and thickness of the fibrotic bands. Color Doppler and spectral Doppler showed decreased vascularity and PSV in lesional area. Prognosis evaluation revealed 25 cases of good prognosis and 5 cases were showed poor prognosis. Wilcoxon Signed Ranks Test revealed no significant difference of PSV was seen in poor prognosis patients. Conclusion: Ultrasonography is a non-invasive diagnostic tool for OSMF. It could be a better diagnostic tool compared to clinical and histopathological examination.

Role of bcl-2 oncoprotein in oral potentially malignant disorders and squamous cell carcinoma: An immunohistochemical study.

Background and Objectives: The product of bcl-2 gene, bcl-2 protein, an anti-apoptotic protein, is known to be over-expressed in potentially malignant disorders and squamous cell carcinoma (SCC) of the oral cavity. The aim of this study is to compare the topographical aspect and degree of bcl-2 over-expression in potentially malignant disorders including leukoplakia, oral submucous fibrosis (OSMF), and oral lichen planus (OLP), with that of the oral squamous cell carcinoma (OSCC), and to determine whether bcl-2 protein can be considered as a tumor marker. Materials and Methods : A group of 60 histo-pathologically diagnosed, formalin-fixed, paraffin embedded tissue samples was included in the study. The study group was further subdivided into four groups: Group I, consisting of oral leukoplakia; Group II, OSMF; Group III, OLP and Group IV, OSCC. These samples were collected from Government Dental College, Bangalore, and then subjected to immunohistochemical (IHC) staining using indirect immunoenzyme labeled streptavidin biotin (LSAB) method. Results : Out of 30 cases of OSCC: 11 (36.7%) cases showed greater supra-basal keratinocyte staining; 15 (50%) cases showed greater number of positive cells in the basal cell layer, with relatively less number of supra-basal cells showing positive staining; and, rest of the 4 (13.3%) cases did not show convincing staining. Among the total 30 cases of potentially malignant disorders: 10 each of leukoplakia, OSMF and OLP, 2 (20%), 2 (20%), 4 (40%) of the cases showed greater supra-basal cell layer positive staining and 8 (80%), 6 (60%), 6 (60%) of them showed greater basal cell staining, respectively. Two cases of OSMF did not show convincing staining. In the cases that were bcl-2 positive: 2 (6.67%) of the OSCC, 3 (30%) of leukoplakia, 2 (20%) of OSMF and 1 (10%) of OLP, showed more than 50% of the cells positive. 25-50% cells were positive in 21 (70%) of OSCC, 6 (60%) of leukoplakia, 4 (40%) of OSMF and 6 (60%) of OLP cases. 10-25% of cells were positive in 4 (13.3%) of OSCC, 1(10%) of leukoplakia, 2 (20%) of OSMF and 3 (30%) of OLP cases. Less than 10% of cells were positive in 3 (10%) of OSCC and 2 (20%) of OSMF cases. Clinical Significance and Conclusion : As definite number of cases showed bcl-2 over expression in our study, the role of bcl-2 in the development and progression of oral neoplasia needs further investigation along with other oncogenes.

Immunohistochemical detection of human telomerase reverse transcriptase in oral cancer and pre-cancer.

Purpose: Telomerase is a specialized ribonucleoprotein complex that stabilizes telomeres by adding "TAG" repeats to the end of chromosomes. The catalytic subunit of telomerase is human telomerase reverse transcriptase (hTERT), whose expression is the critical determinant of telomerase activity. Telomeres and telomerases play an important role in the longevity of cell and are known to conform "immortalization" on neoplastic cells. Although there exists a lot of information on telomerase in oral cancer, very little is known about their expression in leukoplakia and oral submucous fibrosis (OSF). This study addresses this lacuna. Materials and Methods: In this preliminary study, immunohistochemistry (IHC) was used to detect the expression of hTERT protein in oral squamous cell carcinoma (OSCC) (n=30), leukoplakia (n=15), OSF (n=15) and normal oral mucosa (n=10). The cellular localization of immunostain, intensity of stain, mean nuclear labeling index (LI) and mean nuclear labeling score (LS) of hTERT protein were studied. A total number of 1000 cells were counted in each slide. All the data were analyzed using SPSS software version 10.0.2. The cellular localization of cytoplasmic/nuclear/both of hTERT stain, staining intensity and LI were compared across the groups using Pearson's χ2 test. The mean LI and LS for OSF, leukoplakia, OSCC and normal were compared using analysis of variance (ANOVA). A P-value <0.05 was considered to be statistically significant. Results: The mean nuclear LI increased from OSF (22.46±4.53), through normal (28.3±12.3) to OSCC (47.56±21.30) (P=0.002) and from normal (28.3±12.3), through leukoplakia (44.06±14.6), to OSCC (47.56±21.30) (P=0.00). The mean nuclear labeling score was observed to increase from OSF (37.8±15), through normal (64.9±30.7), to OSCC samples (106.9±29.77) (P=0.00) and from normal (64.9±30.7), through leukoplakia (85.6±25.1) to OSCC samples (106.9±29.77) (P=0.00). Conclusion: There was increased expression of hTERT protein in OSCC and leukoplakia samples when compared to normal oral mucosa. The cellular localization, LI and LS in OSF were significantly different from OSCC and leukoplakia.

Expression of heat shock protein70 in oral submucous fibrosis and oral squamous cell carcinoma: An immunohistochemical study.

Background: Heat shock proteins are a highly conserved group of protective cellular proteins whose synthesis is increased in response to a variety of environmental or pathophysiological stresses. Heat shock proteins are useful biomarkers for carcinogenesis in tissues and signal the degree of differentiation and the aggressiveness of cancers. Regulation of heat shock protein 70 (HSP70) expression in oral submucous fibrosis is not known much, and the aim of this study was to evaluate HSP70 expression in oral submucous fibrosis and oral squamous cell carcinoma by immunohistochemical method and to understand the role of HSP70 in tumorigenesis. Materials and Methods: Immunohistochemical method was used to detect HSP70 expression in normal oral mucosa, oral submucous fibrosis (n=30) and oral squamous cell carcinoma (n=20). HSP70 immunoreactivity was correlated with histological and clinicopathological features. Results: A significant increase in expression of HSP70 was observed (P<0.000) as the tissue progressed from oral submucous fibrosis towards oral squamous cell carcinoma. Conclusion: HSP70 is synthesized upon stress situations arising in cells of all living organisms. Expression of HSP70 indicates that stress plays an important role as a predisposing factor in oral submucous fibrosis and its subsequent progression to oral squamous cell carcinoma.

Immunohistochemical evaluation of mast cells and vascular endothelial proliferation in oral submucous fibrosis.

Introduction: Oral submucous fibrosis (OSMF) is a chronic, progressive, scarring disease that predominantly affects the people of south-east Asian origin. Aim: The present study is aimed at comparing and correlating the mast cell density (MCD) and micro vascular density (MVD) in normal mucosa and different grades of OSMF and to analyze their role in the disease progression. Materials and Methods: MCD was assessed immunohistochemically using anti mast cell tryptase and MVD was assessed using anti-factor VIII related von Willebrand factor. Results: The one way comparison of MVD and MCD in normal mucosa and among different grades of OSMF showed a significant increase in MCD and MVD among OSMF cases. Correlation analysis using Pearson correlation coefficient, showed positive correlation between MCD and MVD i.e. as MCD increases there is an exponential increase in MVD. Conclusion: The increase in MVD and MCD reveals their role in the pathogenesis of OSMF, a lesion characterized by progressive fibrosis in early stages and failure of degradation or remodeling in the advanced stages.

Matrix metalloproteinase-1 expression in oral submucous fibrosis: An immunohistochemical study.

Context: Oral submucous fibrosis (OSF) is a form of pathological fibrosis affecting the oral mucosa. There is compelling evidence to implicate the habitual chewing of areca nut with the development of OSF. Because collagens are the major structural components of connective tissues, including oral submucosa, the composition of collagen within each tissue needs to be precisely regulated to maintain tissue integrity. Arecoline stimulates fibroblasts to increase the production of collagen by 150%. Aim: As the role of collagenase is implicated in cleaving the collagen under physical conditions, this study was carried out to evaluate the role of collagenase-1 (matrix metalloproteinase [MMP]-1) in a pathologic condition like OSF. Settings and Design: A total of 40 patients were included in the study, comprising of 30 OSF as Group 1 and 10 normal buccal mucosa tissue as Group 2. Materials and Methods: Both the groups were stained for MMP-1 by the immunohistochemical method using the streptavidin HRP-biotin labeling technique. MMP-1 expression intensity in the epithelium and connective tissue was decreased in Group 1 when compared to Group 2. Statistical Analysis Used: Chi-square test of association was used to determine the difference in the expression of MMP-1 between OSF and normal buccal mucosa and among different histological gradings of OSF. Results: The results were statistically significant. However, there was no statistically significant difference between the expression of MMP-1 among different histological grades of OSF in Group 1.

Comparative study of clinicofunctional staging of oral submucous fibrosis with qualitative analysis of collagen fibers under polarizing microscopy.

Objective : The aim of the study was to assess the severity of the disease in oral submucous fibrosis (OSF), correlate the clinical, functional staging with histopathological staging, and analyze collagen distribution in different stages of OSF using the picrosirius red stain under polarizing microscopy. Materials and Methods : The study included randomly incorporated 50 subjects, of whom 40 were patients with OSF, and 10 were in the control group. Clinical, functional staging in OSF cases was done depending upon definite criteria. A histopathological study was conducted using the hematoxylin and eosin stain and picrosirius red stain. Collagen fibers were analyzed for thickness and polarizing colors. Furthermore, clinical, functional, and histopathological stages were compared. Statistical Analysis : Descriptive data which included mean, SD, and percentages were calculated for each group. Categorical data were analyzed by the chi-square test. Multiple group comparisons were made by one-way ANOVA followed by Student's t-test for pairwise comparisons. For all tests, a P-value of 0.05 or less was considered for statistical significance. Results : As the severity of the disease increased, clinically, there was definite progression in subjective and objective symptoms. Polarized microscopic, examination revealed, there was a gradual decrease in the green-greenish yellow color of the fibers and a shift to orange red-red color with increase in severity of the disease. Thereby, it appeared that the tight packing of collagen fibers in OSF progressively increased as the disease progressed from early to advanced stages. We observed that the comparison of functional staging with histopathological staging was a more reliable indicator of the severity of the disease. Conclusion : In the present study, we observed that mouth opening was restricted with advancing stages of OSF. The investigation also points to the importance of assessing the cases of OSF, especially with regard to functional and histological staging in planning the treatment.

In vivo autofluorescence characteristics of pre- and post-treated oral submucous fibrosis: A pilot study.

Aims and Objectives: To compare the autofluorescence spectra of oral submucous fibrosis (OSF) with normal mucosa, the autofluorescence spectra of OSF before and after treatment with intralesional dexamethasone and hyaluronidase, the clinical improvement following treatment with the changes in autofluorescence spectra and to prove that autofluorescence spectroscopy is a good method for diagnosis and assessment of treatment effectiveness in OSF. Materials and Methods: The study was conducted at the Department of Oral Medicine and Radiology, Tamilnadu Government Dental College and Hospital, Chennai and Division of Medical Physics and Lasers, Department of Physics, Anna University, Chennai in 20 patients seeking medical management for symptomatic OSF and 20 patients who had dental caries only without any oral mucosal diseases and oral habits were used as normal controls. Their ages ranged from 20 to 40 years, including both male and female. In vivo fluorescence emission spectra were obtained using a handheld optical fiber probe attached to a Fluoromax-2 spectrofluorometer. Results: The fluorescence spectrum of OSF had an intense fluorescence emission at 385 nm with a secondary emission peak at 440 nm compared with that of the normal oral mucosa. The average fluorescence spectrum of the post treated OSF mucosa had a lesser intensity around 385 nm and a higher intensity around 440 nm than that of the pre treated OSF mucosa, thereby mimicking the normal oral mucosa. All the three clinical parameters (maximal mouth opening, tongue protrusion and the severity of burning sensation) showed a high statistical significance, with P < 0.001, as in the case of classification of pre treated OSF mucosa from the post treated OSF mucosa using the autofluorescence technique. Conclusion: The change in the fluorescence emission spectrum for both normal and OSF mucosa before and after treatment can be explained by analyzing the changes in the fluorescence intensity of the endogenous fluorophores.

A light microscopic study of fibrosis involving muscle in oral submucous fibrosis.

Oral submucous fibrosis (OSF) is a common pre-malignant condition of the mouth in arecanut chewers in Indian subcontinent. It is characterized by restriction in opening of the mouth, tongue protrusion, and cheek flexibility. Reports of muscle changes in OSF, using light microscopy are few. Incisional biopsy sections of thirty OSF patients were stained with Masson's Trichrome stain, to study the fibrosis involving the muscle. Wide spectrum of changes were observed where fibrosis was being evident sub-epithelially, not extending in to the muscle to cases where only a few remnants of muscle fibers were seen and the missing muscle bundle area being replaced by fibrous tissue. The probable mechanism by which these changes occur is discussed.

Cytological study of copper in oral submucous fibrosis.

BACKGROUND: Habitual arecanut chewing is associated with Oral Submucous Fibrosis (OSF). High copper content in arecanut plays a vital role in pathogenesis of OSF. This study evaluates the copper-staining pattern of buccal epithelial cells in oral cytological smears of non-chewers, chewers, and OSF. MATERIALS & METHODS: Alcohol fixed buccal epithelial smears of 10 histopathologically confirmed cases of OSF, 10 chewers without lesion, and 5 nonchewers were stained with modified Rhodamine technique and studied under the light microscope. Buccal epithelial smears of non-chewers dipped in copper sulphate solution were used as known positive for copper. RESULT: Copper appeared as shades of palered within the cytoplasm of chewers and did not show any stain in non-chewers. Intense red stain was seen in OSF smears as dark granules within the cytoplasm. CONCLUSION: Intense staining of copper in OSF buccal smears, than in the chewers supports the role of copper in the pathogenesis of OSF.

Cell death does not herald epithelial involution ("atrophy") in oral sub mucous fibrosis: a TEM study.

The disease progression in oral submucous fibrosis (OSF) seems to be in a biphasic manner, along both fibroblastic and keratinocytic lineages. The epithelial malignancy is considered to be a sequel of connective tissue changes. "Atrophy" of epithelium makes it amenable to the effect of oral carcinogens. This concept looks rather simplistic in the light of the current understanding of epithelial cell biology. So the concept of epithelial "atrophy" needs redressal against the backdrop of recent investigations. 12 cases of clinically and histologically advanced OSF cases (M:F = 4:8) who were habitual areca-quid chewers comprise the study group. 5 (M:F=1:4) non-OSF, non-areca-nut chewing healthy volunteers, constituted the control group. Biopsy was done and the sections were processed for light and electron microscopy. Cell countings were made based on established criteria for apoptosis and necrosis under the high resolution of a TEM and electron micrographs were taken. The Apoptotic Index (A1) calculated for the diseased mucosa was 3.0 +/- 1.3 and for the control was 2.1 +/- 1.5 (X2 = 1.21, df= 1, p>0.05). The necrotic indices (NI) were respectively, 2.5 +/- 0.6 and 2.0 +/- 1.3 (X2 = 0.24, df = 1, p>0.05). The Absolute Cell death Index (ACI), which is the cumulative figure of apoptosis and necrosis indices, was 5.5 and 4.2 respectively for diseased and normal samples (X2 = 1.8, df = 1, p>0.05). The inability to compute an increased ACI in OSF epithelium, when compared to normal, goes against the concept of epithelial "atrophy". Atrophy envisages an increased apoptotic cell death of keratinocytes, induced by the same signals that caused atrophy and this may contribute to loss of cell of an entire organ. This basic concept in pathology seems to be unfounded with disease. This prompted us for an alternative concept in favour of a reduced proliferation index of the adult stem cell compartment of the oral epithelium. So this study favours the concept of epithelial hypoplasia, rather than atrophy, which causes thinning of surface epithelium in advanced OSF.