International Journal of Dental and Health Sciences Review Article Volume 01,Issue 06

CLASSIFICATION SYSTEMS FOR - FROM PAST TO PRESENT: A REVIEW Vikas Berwal1, Monika Khangwal1, Ravinder Solanki1, Rakshit Khandeparker2, Kiran Savant2, Omkar Shetye3 1. Post Graduate Institute of Dental Sciences, Rohtak, Haryana, 2.Bapuji Dental College and Hospital, Davangere, Karnataka, 3.Goa Dental College and Hospital, Goa

ABSTRACT: Oral Submucous Fibrosis (OSMF) as a disease remains an enigma to the clinicians due to elusive pathogenesis and less well defined classification systems. Over the years, different authors have classified this condition based on clinical, histopathological or functional aspects. But none of these classifications have achieved universal acceptance. Each classification has its own merits and demerits that supersedethe other leading to confusion. This review is presented with the aim to compile all the classification systems available in the literature for the better understanding of the disease among the clinicians. Keywords: Oral Submucous Fibrosis, Classification Systems, Staging and Grading.

INTRODUCTION: “idiopathic palatal fibrosis” [4] and “sclerosing stomatitis” [9]. Oral Submucous Fibrosis (OSMF) is an insidious, chronic, resistant disease The aetiology, once thought to be characterised by and idiopathic, is now confirmed to be progressive fibrosis of the submucosal multifactorial in origin with possible tissues [1]. The disease is regarded as a etiological factors been capsaicin in chillies, precancerous and potentially malignant deficiencies in iron, and essential condition [2,3]. Sushrutha in 600 B. C vitamins[10,11,12,13].However various described a condition similar to OSMF as epidemiological studies, large cross- “Vidari” [4]. OSMF was first described in the sectional surveys, case control studies, and modern literature by Schwartz in 1952 who cohort and intervention studies have coined the term “atrophicaidiopathica provided overwhelming evidence that mucosae oris” to describe an oral fibrosing areca-nut is the main aetiological factor in disease, he discovered in 5 Indian women in OSMF[12-21]. Recent studies have focussed Kenya [5]. Joshi subsequently coined the on changes in the extracellular matrix to term “OSMF” for the condition in 1953 [6]. have a key role in the pathogenesis[15]. The condition is also referred by other These studies indicate an increased names, “diffuse oral submucous fibrosis” [7], synthesis or reduced degradation as “idiopathic scleroderma of the mouth” [8], possible mechanisms in the development of

*Corresponding Author Address: Dr Ravinder Solanki, Post Graduate Institute of Dental Sciences, Rohtak, Haryana, Email id: [email protected]. Berwal V. et al., Int J Dent Health Sci 2014; 1(6):900-913 the disease. Thus, OSMF is now considered clinicians, researchers and academicians in a collagen metabolic disorder. categorization of this potentially malignant disorder according to its biological The signs and symptoms of OSMF are due behaviour and hence its subsequent to fibrosis and hyalinization of sub epithelial medical and surgical treatment. tissues. The most frequently affected locations are the buccalmucosa and the DIFFERENT CLASSIFICATION, STAGING AND retromolar areas. It manifests as a burning GRADING SYSTEMS sensation in themouth, intolerance to The different classification systems existing eating hot andspicy foods, blanching and in literature can be broadly categorised as stiffness ofthe , , follows: vesiculation,excessive salivation, ulceration,pigmentation change, A: Classifications based on clinical aspects recurrentstomatitis, defective gustatory of the disease: sensation,dryness of the mouth , gradual stiffeningand reduced mobility of the soft 1. Desa J. V (1957) palateand the tongue leading to difficulty 2. Wahi P.N. and KapurV.L. et al (1966) inswallowing and hyper nasality of voice,hoarseness of voice (with 3. Ahuja S.S. and Agarwal G.D. (1971) laryngealinvolvement) and occasionally, 4. Bhatt A. P. and Dholakia H.M. (1977) mildhearing loss due to blockage of Eustachian tube [22]. 5. Gupta D.S. and Golhar B.L. (1980)

The characteristic histologic features 6. Pindborg J.J (1989) ofOSMF consist of atrophic epitheliumoften keratinized, generally without reteridges, 7. Katharia S.K. et al (1992) and in advanced cases it may beribbon-like 8. Bailoor D.N. (1993) with juxtaepithelialhyalinization and collagen of varyingdensity [23]. 9. Racher S.K (1993)

The diagnosis and staging of OSMF is an 10. Lai D.R. et al (1995) important aspect for a clinician as it affects 11. Maher R.et al(1996) the treatment and the prognosis [24,25]. Over the years, OSMF has been classified based 12. Haider S.M. et al(2000) on either clinical or histological or both features of the disease. The advantages or 13. Ranganathan K. et al (2001) disadvantages of these classifications 14. Rajendran R. (2003) supersede one another leading to confusion. The purpose of this literature 15. Bose T. and Balan A. (2007) review is to compile and analyse the 16. Kumar K. et al (2007) classifications of OSMF available at different databases so as to assist the 17. Mehrotra D. et al (2009) 901

Berwal V. et al., Int J Dent Health Sci 2014; 1(6):900-913 18. More C.B. et al (2011) Group II: Cases present with symptoms like soreness of mucosa or increased sensitivity 19. Kerr A.R.et al(2011) to chillies. The lesion is diffuse, white, 20. Patil S. and Maheshwari S. (2014) extensive and indurated, involving one or more anatomical sites. 21. Prakash R. et al (2014) Group III: symptoms are mostly due to B:Classifications based on restricted mobility like trismus, stretching histopathological aspects of the disease: at the angles of the mouth altered pronunciation and inability to protrude the 1. Pindborg J.J. and Sirsat S.M. (1966) tongue. Firm submucosal bands are 2. Utsonumiya H. et al (2005) palpable. Surface may be fissured or ulcerated. 3. Kumar K. (2007) 3. Ahuja S.S. and Agarwal G.D.[28]classified C:Classifications based on clinical and based on the extent and type of fibrosis histopathological aspects of the disease: as: 1. Khanna J.N. and Andrade N.N. Class I: Localised fibrous bands in the cheek (1995) extending from the superior to the inferior A: CLASSIFICATIONS BASED ON THE fornix on one or both sides. In order of CLINICAL ASPECTS OF THE DISEASE: frequency, the bands are mostly found on the , the premolar region or the second [26] 1. Desa J.V. divided OSMF into 3 stages: molar region.

Stage I: Stomatitis and vesiculation Class II: Generalised diffuse hardening of Stage II: Fibrosis the sub epithelial tissues extending from the cheek and hard to the soft Stage III: As its sequelae palate, uvula and the faucial pillars. Occasionally, the hardening might extend 2. Wahi P.N. and Kapur V.L. [27] et al to the lining mucosa of the pharynx. classified OSMF based on the clinical features, severity and extent of Class III: Combination of the above two involvement into 3 groups: types where the fibrous bands are associated with a generalised diffuse form Group I: Usually there are no symptoms of submucous fibrosis. referable to mucosal involvement. The lesion affects one or other commonly 4. Bhatt A. P. and Dholakia H.M. involved anatomical site, is focal in [29]clinically grouped the patients into character, shows pallor or whitish three grades as: coloration, wrinkling of mucosa and minimal induration.

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Berwal V. et al., Int J Dent Health Sci 2014; 1(6):900-913 Grade I: Comprised of mild and early cases Stage II: Fibrosis occurring in the healing with a very slight fibrous bands and little vesicles and ulcers is the hallmark of the closure of the mouth. stage.

Grade II: Moderately pronounced  Early lesions demonstrate blanching symptoms with fibrous bands extending of the oral mucosa. from the cheek to the palate.  Older lesions include vertical and Grade III: Excessive amount of fibrosis circular palpable fibrous bands in involving the cheek, palate, uvula, tongue the buccal mucosa and around the and the lips with narrow opening of the mouth opening or lips resulting in mouth. mottled marble like appearance of the mucosa because of the vertical 5. Gupta D.S. and Golhar B.L. [30] classified thick fibrous bands in association into four stages based on the increasing with blanched mucosa. intensity of trismus as:  Specific findings include reduction of Very early stage: The patients complain of mouth opening, stiff and small burning sensation in the mouth or tongue, blanched and leathery floor ulceration without difficulty in mouth of the mouth, fibrotic and opening. depigmented gingiva, rubbery soft Early stage: Along with burning sensation, palate with decreased mobility, the patients complain of slight difficulty in blanched and atrophic tonsils, opening the mouth. shrunken bud like uvula and sunken cheeks, not commensurate with age Moderately advanced stage: The trismus is or nutritional status. marked to such an extent that the patient cannot open his/her mouth more than two Stage III: Sequelae of OSMF as follows: fingers width therefore experiencing  is found in more than difficulty in mastication. 25 % of the individuals with OSMF. Advanced stage: Patient is undernourished,  Speech and hearing defects may anaemic and has a marked degree of occur due to involvement of the trismus. tongue and eustachian tubes. 6. Pindborg J.J [31] divided OSMF into 3 7. Katharia S.K. et al [32] described a stages as: scoring system based on the mouth Stage I: Stomatitis includes erythematous opening present between upper and mucosa, vesicles, mucosal ulcers, melanotic lower central incisors as: mucosal pigmentations and mucosal petechiae.

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Berwal V. et al., Int J Dent Health Sci 2014; 1(6):900-913 Score 0: Mouth opening is greater than 41 extended with the mouth wide mm open: Males 5 to 6 cm, Females 4.5 to 5.5 cm). Score 1: Mouth opening between 37 to 40 mm  Cheek flexibility: CF= V1-V2 where V2 Score 2: Mouth opening between 33 to 36 is a point measured between at mm one-third the distance from the angle of the mouth on a line Score 3: Mouth opening between 29 to 32 joining the tragus of the ear to the mm angle of the mouth. The patient is Score 4: Mouth opening between 25 to 28 then asked to blow his cheeks fully mm and the distance between the two Score 5: Mouth opening between 21 to 24 points is marked on the cheek as mm V1. Mean values for cheek flexibility: Males 1.2 cm and Score 6: Mouth opening between 17 to 20 Females 1.08 cm. mm

Score 7: Mouth opening between 13 to 16  Burning sensation on taking spicy or mm hot foods only.

Score 8: Mouth opening between 09 to 12 Stage II: Moderate OSMF mm  Moderate to severe blanching. Score 9: Mouth opening between 05 to 08 mm  Mouth opening reduced by 33%.

Score 10: Mouth opening between 00 to 04  Cheek flexibility also mm demonstrably reduced. 8. Bailoor D.N. [33] classified on the basis of  Burning sensation in absence of diagnosis as: stimuli. Stage I: Early OSMF  Palpable bands felt.  Mild blanching.  Lymphadenopathy either  No restriction in mouth opening unilateral or bilateral. (normal distance between central  Demonstrable anaemia on incisor tips: Males 35 to 45 mm, haematological examination. Females 30 to 42 mm). Stage III: Severe OSMF  No restriction in tongue protrusion (normal mesioincisal angle of the  More than 66% reduction in the upper central incisor to the tip of mouth opening, cheek flexibility the tongue when maximally and tongue protrusion.

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Berwal V. et al., Int J Dent Health Sci 2014; 1(6):900-913  Tongue may appear fixed. seen in the lips, cheeks and palate. Larynx is free from disease and  Severe burning sensation, patient respiration is not affected. is unable to do day to day work. Stage III: Stage of sequelae and  Ulcerative lesions may appear on complications the cheek.  Leukoplakia changes in the  Thick palpable bands. mucosa.

 Bilateral lymphadenopathy.  An ulcerating malignant lesion 9. Racher S.K [34] classified into 3 stages may be seen involving the based on habits as: cheeks, oropharynx or the tongue. Stage I: Stage of Stomatitis and Vesiculation  Patients are predisposed to  Characterised by recurrent develop under the stomatitis and vesiculation. influence of carcinogens. Patient complains of burning [31] sensation in the mouth and 10. Lai D.R. grouped OSMF on the basis inability to eat pungent food. of interincisal distance as:

 The examination reveals vesicles Group A: Interincisal distance greater than on the palate that may rupture 35 mm. and a superficial ulceration may Group B: Interincisal distance 30 to 35 mm. be seen. Some amount of fibrosis can be seen. Group C: Interincisal distance 20 to 30 mm.

Stage II: Stage of fibrosis Group D: Interincisal distance less than 20 mm.  There is inability to open the mouth [35] completely and stiffness in 11. Maher R. et al classified on the basis mastication. As disease advances, of area of involvement in the oral cavity. there is difficulty in blowing the He divided the intra-oral regions into cheeks and protruding the tongue. eight sub regions viz palate, posterior one-third of the buccal mucosa, middle  On examination, there is increasing one-third of the buccal mucosa, anterior fibrosis in the submucosal. Mucosa one-third of the buccal mucosa, upper is blanched and white. Lips and labial mucosa, tongue and floor of the cheeks are stiff. Dorsum of the mouth and looked for disease tongue may show of involvement in each to assess the papillae. Blanching and stiffness of extent of clinical disease. This was the mucosa of the floor of the mouth is less marked than that 905

Berwal V. et al., Int J Dent Health Sci 2014; 1(6):900-913 further grouped into three categories Group III: Mouth opening less than 20 mm. as: Group IV: OSMF advanced with limited 1. Involvement of one-third or less mouth opening. Precancerous or cancerous of the oral cavity changes are seen throughout the mucosa.

2. Involvement of one-third to two- 14. Rajendran R. [38] reported the clinical third of the oral cavity (if 4 to 6 features of OSMF as follows: intra-oral sites are involved) Early OSMF: Comprises of burning 3. Involvement of greater than sensation in the mouth, blisters especially two-third of the oral cavity. on the palate, ulceration or recurrent generalized inflammation of oral mucosa, 12. Haider S.M. [36] classified on the basis of excessive salivation, defective gustatory severity of disease taking objective sensation and dryness of mouth. parameters like mouth opening into consideration. Advanced OSMF: Comprises of blanched and slightly opaque mucosa, fibrous bands I: Clinical staging in the buccal mucosa running in vertical 1. Faucial bands only. direction. Palate and faucial pillars are the areas first involved with gradual 2. Faucial and buccal bands. impairment of tongue movement and difficulty in mouth opening. 3. Faucial, buccal and labial bands. 15. Bose T. and Balan A. [39] classified based on clinical features as: II: Functional staging Group A: Mild cases 1. Mouth opening greater than 20 mm. Only occasional symptoms, pallor, vesicle formation, presence of one or two solitary 2. Mouth opening between 11 palpable bands, loss of elasticity of mucosa, to 19 mm. variable tongue involvement with 3. Mouth opening less than 10 protrusion beyond vermillion border. mm. Mouth opening is greater than 3 cm.

13. Ranganathan K. et al [37] divided OSMF Group B: Moderate cases based on mouth opening as follows: Symptoms of soreness of mucosa or Group I: Only symptoms with no increased sensitivity to chillies, diffuse demonstrable restriction of mouth opening. involvement of the mucosa, blanched appearance, buccal mucosa tough and Group II: Limited mouth opening 20 mm inelastic fibrous bands palpable, and above. considerable restriction of mouth opening

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Berwal V. et al., Int J Dent Health Sci 2014; 1(6):900-913 (1.5 to 3 cm) and variable tongue Grade IV: Symptoms of grade III, fibrosis movement. and mouth opening of 0 to 5 mm. Suggested treatment is abstinence from Group C: Severe cases habit and surgical management. Symptoms are more severe, broad fibrous 18. More C.B. et al [42] gave the following bands palpable, blanched opaque mucosa, classification based on clinical and rigidity of mucosa, very little opening of functional parameters as: mouth (less than 1.5 cm), depapillated tongue and protrusion of tongue very much I: Clinical staging: restricted. Stage 1 (S1): Stomatitis and/or blanching of 16. Kumar K. et al [40] categorised OSMF oral mucosa. based on mouth opening as follows: Stage 2 (S2): Presence of palpable fibrous Stage I: Mouth opening greater than 45 bands in buccal mucosa and/or oropharynx, mm. with/without stomatitis.

Stage II: Mouth opening between 20 to 44 Stage 3 (S3): Presence of palpable fibrous mm. bands in buccal mucosa and/or oropharynx, and in any other parts of oral cavity, Stage III: Mouth opening less than 20 mm. with/without stomatitis. 17. Mehrotra D. et al [41] suggested a Stage 4 (S4): clinical grading of the disease and treatment methods as: A: Any one of the above stage along with other potentially malignant disorders e.g. Grade I: Stomatitis, burning sensation in the oral leukoplakia, oral , etc. buccal mucosa and with no detection of fibres. Suggested treatment is abstinence B: Any one of the above stage along with from habit and medicinal management. oral carcinoma.

Grade II: Symptoms of grade I, palpable II: Functional staging: fibrous bands, involvement of soft palate M1: Inter-incisal mouth opening up to or and maximal mouth opening of 26 to 35 greater than 35 mm. mm. Suggested treatment is abstinence from habit and medicinal management. M2: Inter-incisal mouth opening between 25 to 35 mm. Grade III: Symptoms of grade II, blanched oral mucosa, involvement of tongue and M3: Inter-incisal mouth opening between maximal mouth opening of 6 to 25 mm. 15 to 25 mm. Suggested treatment is abstinence from habit and surgical management. M4: Inter-incisal mouth opening less than 15 mm.

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Berwal V. et al., Int J Dent Health Sci 2014; 1(6):900-913 19. Kerr A.R. et al [43] gave the following grading system for OSMF as:

Grade 1: Mild: Any features of the disease triad for OSMF (burning, depapillation, blanching or leathery mucosa) may be reported and inter-incisal opening greater than 35 mm.

Grade 2: Moderate: Above features of OSMF and inter-incisal limitation of opening Figure 1: Diagrammatic representation of between 20 to 35 mm. various shapes of soft palate. Grade 3: Severe: Above features of OSF and It was observed that type 1 variant was the inter-incisal opening less than 20 mm. most common, seen in stage 2 OSMF 42 Grade 4A: Above features of OSMF with (based on More C.B. et al classification ) other potentially malignant disorders on and type 3 variant was common in stage 3 clinical examination. OSMF. The authors concluded that in OSMF, type 1 and 2 are commonly seen but Grade 4B: Above features of OSMF with any as the diseases advances, these are grade of oral epithelial dysplasia on biopsy. replaced by type 3 and 6 variants.

Grade 5: Above features of OSMF with oral 21. PatilS. and Maheshwari S. [45] suggested . a new classification based on cheek flexibility. Here, cheek flexibility was 20. Prakash R. et al [44] assessed the measured as a distance in millimetres, morphologic variants of soft palate by from maxillary incisal midline to the conducting a clinic-radiological study. cheek retractor during retraction. The authors based on these variants Normal cheek flexibility observed was: assessed the severity of OSMF to Males 35 to 45 mm, Females 30 to 40 establish it as a basis for staging of mm. OSMF. Six morphologic variants were delineated as follows( Figure 1): Grade 1 (Early): Cheek flexibility of 30 mm and above. Type 1: Leaf shaped Grade 2 (Mild): Cheek flexibility between 20 Type 2: Rat tail shaped to 30 mm. Type 3: Butt shaped Grade 3 (Moderate): Cheek flexibility less Type 4: Straight line than 20 mm.

Type 5: Deformed S

Type 6: Crook shaped 908

Berwal V. et al., Int J Dent Health Sci 2014; 1(6):900-913 Grade4 (Severe): Any of the above of fibroblasts. Blood vessels are completely condition without concurrent presence of obliterated or narrowed. Inflammatory cells potential malignant lesions. are lymphocytes and plasma cells.

Grade 5 (Advanced): Any of the above 2. Utsonumiya H. et al [46] divided OSMF condition with concurrent presence of oral based on the concept of Pindborg J.J. carcinoma. and Sirsat S.M. and modified it as follows: B: CLASSIFICATIONS BASED ON HISTOPATHOLOGICAL ASPECTS OF THE Early stage: Large number of lymphocytes DISEASE: in the sub epithelial and connective tissue zones along with myxedematous changes. 1. Pindborg J.J. and Sirsat S.M. [9] Intermediate stage: Granulation changes Very early stage: Finely fibrillar collagen close to the muscle layer and hyalinization dispersed with marked oedema with plump appears in sub epithelial zone where blood young fibroblasts containing abundant vessels are compressed by fibrous bundles. cytoplasm. Blood vessels are dilated and Reduced inflammatory cells in sub epithelial congested. Inflammatory cells, mainly layer are seen. polymorphonuclear leukocytes with occasional eosinophils are found. Advanced stage: Inflammatory cell infiltrate hardly seen. Number of blood vessels Early stage: Juxta-epithelial area shows dramatically less in the sub epithelial zone. early hyalinization. Collagen is still in Marked fibrous areas with hyaline changes separate thick bundles. Moderate numbers extending from sub epithelial to superficial of plump young fibroblasts are present. muscle layers are seen. Atrophic, With dilated and congested blood vessels. degenerative changes start in muscle fibres. Inflammatory cells are primarily lymphocytes, eosinophils and occasional 3. Kumar K. et al [40] graded OSMF as plasma cells. follows:

Moderately advanced stage: Collagen is Grade I: Loose, thick and thin fibres. moderately hyalinised. Thickened collagen Grade II: Loose or thick fibres with partial bundles are separated by slight residual hyalinisation. oedema. Fibroblastic response is less marked. Blood vessels are either normal or Grade III: Complete hyalinisation. compressed. Inflammatory exudate consists of lymphocytes and plasma cells. C: CLASSIFICATIONS BASED ON CLINICAL AND HISTOPATHOLOGICAL ASPECTS OF Advanced stage:Collagen is completely THE DISEASE: hyalinised. A smooth sheet with no [47] separate bundles of collagen is seen. 1. Khanna J.N. and Andrade N.N. Oedema is absent. Hyalinised area is devoid developed a group classification system

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Berwal V. et al., Int J Dent Health Sci 2014; 1(6):900-913 to aid in the surgical management of bands palpable at the soft palate, OSMF. It is the most accepted pterygomandibular raphe and anterior classification by the clinicians. faucial pillars.

Group I: Very early cases: Histology:Juxta-epithelial hyalinization present, thickened collagen bundles, Clinically:Common symptom is burning residual edema, constricted blood vessels, sensation in the mouth, acute ulceration mature fibroblasts with scanty cytoplasm and recurrent stomatitis and not associated and spindle-shaped nuclei, inflammatory with mouth opening limitation. exudate which consists of lymphocytes and Histology:Fine fibrillar collagen network plasma cells, markedly atrophic interspersed with marked oedema, blood with loss of rete pegs, muscle fibres seen vessels dilated and congested,large with thickened and dense collagen fibres. aggregate of plump young fibroblasts Group IVA: Advanced cases present withabundant cytoplasm, inflammatory cells mainly consist of Clinically: Severe trismus, interincisal polymorphonuclear leukocytes with few distance of less than 15 mm, thickened eosinophils. The epithelium is normal. faucial pillars, shrunken uvula, restricted tongue movement, presence of circular Group II: Early cases band around the entire lip and mouth. Clinically: Buccal mucosa appears mottled Group IVB: Advanced cases and marble like, widespread sheets of fibrosis palpable, interincisal distance of 26 Clinically: Presence of to 35 mm. hyperkeratoticleukoplakia and/or squamous cell carcinoma. Histology:Juxta-epithelial hyalinization present, collagen present as thickened but Histology: Collagen hyalinised smooth separate bundles, blood vessels dilated and sheet, extensive fibrosis, obliterated congested, young fibroblasts seen in mucosal blood vessels, eliminated moderate number, inflammatory cells melanocytes, absent fibroblasts within the mainly consist of polymorphonuclear hyalinised zones, total loss of epithelial rete leukocytes with few eosinophils and pegs, presence of mild to moderate atypia occasional plasma cells, flattening or and extensive degeneration of muscle shortening of epithelial rete-pegs evident fibres. with varying degree of keratinization. The authors are of the view that patients in Group III: Moderately advanced cases group I and group II can be managed by symptomatic treatment, whereas those in Clinically: Trismus, interincisal distance of group III and group IV definitely require 15 to 25 mm, buccal mucosa appeal's pale surgical management. firmly attached to underlying tissues, atrophy of vermilion border, vertical fibrous 910

Berwal V. et al., Int J Dent Health Sci 2014; 1(6):900-913 CONCLUSION: staging as clinical appearance holds the most important value in staging OSMF. In OSMF, the initial diagnosis is of utmost Treatment if done according to the staging importance, as the treatment and its and grading helps in management & better prognosis greatly depend on its staging. An prognosisfor the patient. Hence treatment attempt is made to update the knowledge should be done as per the staging and on classification schemes for OSMF so as to grading. We hope this review helps assist in categorisation of this premalignant academicians, clinicians as well as condition and to aid in early diagnosis researchers in getting a broad view on thereby leading to timely management. An various classification systems and increased emphasis is placed on clinical contribute to optimal patient management.

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