BMJ Case Reports 2010;
We propose the use of zinc acetate
doi:10.1136/bcr.10.2009.2348
Novel treatment (new
drug/intervention; established
drug/procedure in new situation)
Zinc and vitamin A can minimise
the severity of oral submucous
fibrosis
Richa Dhariwal1, Sanjit Mukherjee2,
Sweta Pattanayak (Mohanty)1, Avirup
Chakraborty2, Jay Gopal Ray1,2, Keya
Chaudhuri2
Author Affiliations
1
Dr R Ahmed Dental College & Hospital,
Kolkata-700014, India, Oral and
Maxillofacial Pathology, 114, Acharya
Jagadish Chandra Bose Road, Kolkata,
700014, India
2
Indian Institute of Chemical Biology,
Molecular and Human Genetics, 4, Raja Sc
Mullick Road, Kolkata, 700032, India
Correspondence to
Jay Gopal Ray, jaygopalray@yahoo.co.in
Published 11 May 2010
Summary
We report a case of a 24-year-old man who
presented with a complaint of reduced mouth
opening and a burning sensation. On
examination, he was clinically diagnosed with
oral submucous fibrosis (OSF). Following
routine biopsy and histopathological
confirmation of OSF, the patient was
supplemented with zinc acetate along with
vitamin A and was followed up for 4 months.
Following treatment the patient reported
increased mouth opening and a reduced
burning sensation. Histopathologically re-
epithelialisation was evident along with the
appearance of normal rete pegs. The data for
mouth opening, collagen content and
epithelial thickness of six other cases similarly
treated are also presented, showing a
significant increase in mouth opening and
epithelial thickness and decrease in collagen
content.
and vitamin A for the management of OSF.
Background
Oral submucous fibrosis (OSF) is an
insidious chronic progressive precancerous
condition of the oral cavity and oropharynx.
Although it is reported in many parts of the
world, including the UK,1 South Africa2 and
many southeast Asian countries,3,4 it is
mainly prevalent in the Indian subcontinent
in all age groups and across all
socioeconomic strata.3,4 A large proportion of
these precancerous lesions convert to
squamous cell carcinoma, the malignant
transformation rate being in the order of
7.6%.5
The aetiology of OSF is ill understood, but
chewing of the areca nut in isolation or in
combination with betel leaf or other tobacco
products6,7 has been implicated in the disease.
Other factors such as ingestion of chillies,
deficiencies of nutrients, trace elements,
vitamins, hypersensitivity to various dietary
constituents, genetic and immunologic
predisposition have also been suggested to be
involved in the progression of this disease.5,7
10
The basic change is a fibro-elastic
transformation of the connective tissue in the
lamina propria preceded by vesicle
formation. In its later stages the oral mucous
membrane becomes stiff and the patient
suffers from trismus or difficulty in opening
his or her mouth and a resultant difficulty in
eating.11
No satisfactory treatment for OSF has been
described, although a wide range of treatment
modalities have been proposed. Treatment
with steroids, enzymes, micronutrients and
minerals, turmeric, IFN- and multiple
surgical modalities have been tried.
The purpose of the present study is to
monitor seven cases before and after
administration of zinc acetate along with
vitamin A supplement, after motivating the
patients to stop chewing areca nut. Following
treatment, the patients reported significant
increased mouth opening and reduced
burning sensation. Re-epithelialisation was
clearly evident histologically. Quantitative
image analysis noted a significant increase in
epithelial thickness following treatment. This
case report is intended to create awareness of
the beneficial effect of zinc acetate and
vitamin A in the treatment of this
precancerous condition.

Case presentation
A 24-year-old man presented to the
Department of Oral and Maxillofacial
Pathology at the Dr R Ahmed Dental College
& Hospital, Kolkata, India, with a complaint
of progressive reduction in mouth opening
during the previous year, burning sensation
on eating spicy food, and occasional vesicle
formation on the palate. He denied any other
significant medical issue. He gave a history
of chewing gutkha (commercially prepared
areca nut with smokeless tobacco and other
flavouring agents), 78 packets per day for a
period of 78 years, and also smoking bidi.
Intraorally, on inspection the maximal inter- Figure 1
incisal distance was noted to be 23 mm (fig (A) Maximal inter-incisal distance of 23 mm
1A). Generalised blanching of the bilateral on Vernier scale. (B) Limited mouth opening
buccal mucosa was observed. Small vesicles with severely blanched palatal mucosa and
were present on the hard palate (fig 1B, C). vesicle formation. (C) Buccal mucosa
On palpation tense fibrous bands were felt in showing severe blanching, a marble-like
the buccal mucosa. A biopsy was taken from appearance, and fibrosis.
the representative site of the buccal mucosa
and histopathological evaluation was done Investigations
after haematoxylin and eosin (H&E) staining, The patient was subjected to a routine
which revealed the presence of stratified haemogram which was within normal limits
squamous epithelium of variable thickness and a routine orthopantomogram which did
(520 cell layers) along with surface not reveal any other aetiology for trismus.
parakeratinisation. The underlying supporting
connective tissue showed hyalinisation and Treatment
homogenisation interspersed with mature The patient was treated for 4 months with
spindle shaped fibrocytes and paucity of zinc actetate tablets, 50 mg three times daily,
blood capillaries. and vitamin A 25000 IU, once daily, with
regular follow-up at an interval of 1 month.
Outcome and follow-up
After 2 months of treatment and cessation of
oral habits (chewing areca nut and smoking
bidi), the patient reported an increased mouth
opening of 29 mm with complete relief from
burning sensation. On completion of 4
months of treatment the patient was recalled
and the inter-incisal distance was now 42 mm
(fig 2A). Intraoral examination revealed near
normal colour of the mucosa with a few
palpable bands on the buccal mucosa. A
follow-up incisional biopsy was performed
after 4 months and the specimen was
obtained from the adjacent area of the
previous biopsy site. The section revealed the
presence of stratified squamous epithelium
(2025 cell layers) with the presence of rete
pegs and surface keratinisation. The
underlying connective tissue showed
hyalinisation and homogenisation with
obliterated blood vessels (fig 3B). The
epithelial thickness pre- and post-treatment
was measured with the help of Leica QWin
plus digital image processing and analysis
software (Leica Microsystems Ltd,
Switzerland). A significant (p<0.0001, Figure 2
Students t test) increase in average epithelial (A) Post-supplementation maximal inter-
thickness was observed which suggests re- incisal distance of 42 mm on Vernier scale.
epithelialisation following zinc and vitamin (B) Post-supplementation increased mouth
A supplement. The collagen content per unit opening with palatal mucosa showing near
protein was measured biochemically (Sircol normal colour with few vesicles along with
collagen assay kit, UK), and were 95.83 blanching limited to the lateral aspect of the
g/mg protein and 96.84 g/mg protein at soft palate. (C) Post-supplementation near
pre- and post-zinc acetate treatment, normal colour of buccal mucosa with reduced
respectively. fibrosis.

Figure 3
(A) Pre-treatment microphotograph showing
atrophic stratified squamous epithelium with
subepithelial hyalinisation and
homogenization (haematoxylin and eosin
(H&E) 10). (B) Post-treatment
microphotograph showing keratinised
stratified squamous epithelium with rete
ridges and subepithelial hyalinisation and
homogenisation. (H&E 10).
Discussion
Zinc plays a wide and pivotal biological role
in the system of the human bodyfor
example, in DNA synthesis and cell
divisionand is a constituent of many
enzymes, including dehydrogenases and
carbonic anhydrase. Our earlier observation
noted a pronounced reduction in tissue zinc
content of OSF subjects.9 Moreover, zinc is
an antagonist of copper; it has been suggested
that the copper released from areca nut might
upregulate lysyl oxidase activity that leads to
increased collagen synthesis and cross-
linking. In the present case study, vitamin A,
known to stabilise epithelium, was used
along with zinc to promote re-
epithelialisation and reduce burning sensation
in the mouth.
The same treatment protocol was followed
for six other OSF cases with similar
symptoms. Although, for the case described
above, we could not detect any significant
alterations in collagen content, in some of the
other cases attending the Department of Oral
and Maxillofacial Pathology at the Dr R
Ahmed Dental College & Hospital, the
collagen content was found to be reduced: the
average collagen content per unit protein of
total seven patients, including the case
described, was found to be 65.521.15 g/mg
protein and 64.417.1 g/mg protein before
and after 4 months of supplementation,
respectively (table 1). A concomitant
increase in average maximal inter-incisal
distance (26.56.8 mm vs 32.39.0 mm) and
reduction in burning sensation were
noticeable. Measurement of epithelial
thickness in H&E stained sections revealed a
highly significant increase (p<0.0001,
Students t test), suggesting re-
epithelialisation except in one case (table 2).
Further experimentation is needed to study
the causal relationship of mouth opening and
collagen content in relation to the above
treatment in this disease process.
Table 1
Inter-incisal distance and collagen content of
seven oral submucous fibrosis patients pre-
and post-treatment with zinc acetate and
vitamin A
Pre- Inter- Collag Post- Inter- Collag flavouring agents plays a crucial role in
treatm incisa en treatm incisal en the aetiology of oral submucous fibrosis.
ent l (g/m ent distan (g/m
distan g of ce g of Cessation of oral habits along with zinc
ce protei (mm) protei and vitamin A supplementation resulted
(mm) n) n) in a reduction in clinical symptoms.
A significant increase in average
Pt 1 24 55.9 Pt 1 25 55.97 epithelial thickness was observed post-
Pt 2 29 86.3 Pt 2 29 65.4 supplementation.

Pt 3* 23 95.83 Pt 3* 42 96.84 Footnotes

Pt 4 16 32.69 Pt 4 23 39.69 Competing interests: None.
Pt 5 29 55.45 Pt 5 32 67.42
Pt 6 38 71.79 Pt 6 47 59.57
Pt 7 26 60.7 Pt 7 28 65.9
Patient consent: Patient/guardian consent
was obtained for publication.
Mean 26.5 65.5 32.3 64.4
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