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Textbooks in Contemporary Dentistry

This textbook series presents the most recent advances in all fields of
dentistry, with the aim of bridging the gap between basic science and
clinical practice. It will equip readers with an excellent knowledge of
how to provide optimal care reflecting current understanding and
utilizing the latest materials and techniques. Each volume is written by
internationally respected experts in the field who ensure that
information is conveyed in a concise, consistent, and readily intelligible
manner with the aid of a wealth of informative illustrations. Textbooks
in Contemporary Dentistry will be especially valuable for advanced
students, practitioners in the early stages of their career, and university
instructors.
Editors
Saman Warnakulasuriya and Kannan Ranganathan

Oral Submucous Fibrosis

A Guide to Diagnosis and Management
Editors
Saman Warnakulasuriya
Faculty of Dentistry Oral and Craniofacial Sciences, King's College
London, London, UK

Kannan Ranganathan
Oral and Maxillofacial Pathology, Ragas Dental College and Hospital,
The TN Dr MGR Medical University, Chennai, Tamil Nadu, India

ISSN 2524-4612 e-ISSN 2524-4620

Textbooks in Contemporary Dentistry
ISBN 978-3-031-12854-7 e-ISBN 978-3-031-12855-4
https://doi.org/10.1007/978-3-031-12855-4

© The Editor(s) (if applicable) and The Author(s), under exclusive

license to Springer Nature Switzerland AG 2023

This work is subject to copyright. All rights are solely and exclusively
licensed by the Publisher, whether the whole or part of the material is
concerned, specifically the rights of translation, reprinting, reuse of
illustrations, recitation, broadcasting, reproduction on microfilms or in
any other physical way, and transmission or information storage and
retrieval, electronic adaptation, computer software, or by similar or
dissimilar methodology now known or hereafter developed.

The use of general descriptive names, registered names, trademarks,

service marks, etc. in this publication does not imply, even in the
absence of a specific statement, that such names are exempt from the
relevant protective laws and regulations and therefore free for general
use.

The publisher, the authors, and the editors are safe to assume that the
advice and information in this book are believed to be true and accurate
at the date of publication. Neither the publisher nor the authors or the
editors give a warranty, expressed or implied, with respect to the
material contained herein or for any errors or omissions that may have
been made. The publisher remains neutral with regard to jurisdictional
claims in published maps and institutional affiliations.

This Springer imprint is published by the registered company Springer

Nature Switzerland AG
The registered company address is: Gewerbestrasse 11, 6330 Cham,
Schweiz
“We dedicate this book to our families, teachers, and colleagues without
whose support neither of us would be where we are”
Prof. Saman WarnakulasuriyaProf. Kannan Ranganathan
Foreword

I am privileged and honored to write

the foreword for the book titled “Oral Submucous Fibrosis: Guide to
Diagnosis and Management.” This comprehensive text covers all aspects
of this deadly disease mostly prevalent in South and Southeast Asia.
The text describes the disease in detail, from its historical aspects to its
etiology, pathogenesis, clinical presentation, classification systems,
diagnostic methods, histopathological aspects, mechanisms of
malignant transformation, and treatment. It also includes sections on
areca nut cessation and various other interventions. It has been a long-
felt need to compile all the different aspects of this common health
problem in South and Southeast Asia under a single title. This affords a
unique opportunity for undergraduates, postgraduates, researchers,
and other relevant health professionals to read about every aspect of
the disease in one place. The chapters describe a complex subject
matter in a simple form accessible to any kind of audience.
The textbook is edited by two eminent globally recognized
academics in the field of oral cancer and oral potentially malignant
disorders (OPMDs). Professor Saman Warnakulasuriya from King’s
College, London, is a world-renowned professor who has spent many
decades of his academic career conducting extensive research on oral
cancer and OPMD. His in-depth knowledge on the subject of oral
submucous fibrosis is unparalleled, and this would have certainly
helped in bringing this book to the highest standards. Professor K.
Ranganathan from Ragas Dental College, Chennai, India, is a well-
respected oral pathologist who has contributed immensely to the
subject both nationally and internationally. In addition, his vast clinico-
pathological knowledge on submucous fibrosis would have contributed
immensely to editing this book. They have brought together a well-
experienced group of academics, clinicians, and researchers to share
their enormous experience in compiling this historic text on oral
submucous fibrosis.
While congratulating the editors and contributors for this timely
contribution to medical literature, I highly recommend this book for
anyone who wants to gain in-depth knowledge on oral submucous
fibrosis.
Prof. W. M. Tilakaratne
Preface
Oral submucous fibrosis was first described in early 1950s, and since
its discovery, much has been written about this disease. Some early
theories about its causation are now outdated, and there is sufficient
evidence that areca nut consumption is the major cause of this disease.
Because of the important recent developments on many aspects of oral
submucous fibrosis (OSF), it is our goal to provide an accurate up-to-
date textbook that has a comprehensive coverage on this disease and to
reflect on the latest advances that are important to the clinicians for the
diagnosis and management of OSF and to the pathologists who
contribute to the diagnostic services. The precancerous nature of this
disease has been known for several decades, and based on the WHO
nomenclature developed in 2005, OSF was established as an oral
potentially malignant disorder (OPMD). In fact, epidemiological surveys
indicate that oral submucous fibrosis is the most prevalent OPMD in
South Asia and the western Pacific region, and hence we recognize its
importance as a clinical entity.
 This comprehensive textbook consisting of 22 chapters is written by
invited experts in the field. The contributors are well-known teachers
in dental schools, mostly from South Asia, and this book has drawn
them together in a unique collaboration to provide an all-encompassing
review of the current state of knowledge on this disease.
For didactic purposes, the chapters in the textbook are organized
into six parts. The first set of chapters (► Chaps. 1–7) focus on the
historical and clinical aspects of the disease. The second and third sets
of chapters (► Chaps. 8–12) explore the etiology and etiopathogenesis.
The fourth set of chapters (► Chaps. 13–15) describe the investigative
techniques, and the fifth set of chapters (► Chaps. 16–18) examine the
current concepts on the management of OSF. The final set (► Chaps.
19–21) deals with the management of addiction to areca nut to
facilitate interventions on the cause of this disease. In the final chapter,
we also provide a comprehensive bibliography for additional reading
and in the appendix some historical aspects of authors who made
contributions to our current understanding of this disease.
The book is primarily intended for undergraduate and graduate
students in dentistry and could act as a handy reference book to
primary care physicians in Southeast Asia, who regularly see areca nut
chewers in their clinical practice. We hope that the readers will
appreciate the multidisciplinary prospective of the textbook, extending
the book’s usefulness to a wider audience of caregivers.
We thank Alison Wolf for commissioning this textbook and
Sivachandran Ravanan for the assistance received, who acted as the
Project Coordinator for Springer Nature. Editorial assistance given to us
by Kavitha Loganathan during numerous occasions throughout this
book project is greatly appreciated.
Saman Warnakulasuriya
Kannan Ranganathan
London, UK
Chennai, Tamil Nadu, India
June 2022
Abbreviations
2G 2-Guanine
AA Adenine adenine
AG Adenine guanine
ALK5 Activin-like kinase 5
AN Areca nut
bFGF Basic fibroblast growth factor
BMP Bone morphogenetic protein
BMP1 Bone morphogenetic protein 1
BQ Betel quid
C/T Cytosine/thymine
CC Cytosine cytosine
COL1A1 Collagen 1A1
COL1A2 Collagen 1A2
COLase Collagenase-1
CREB3L1 cAMP response element-binding protein 3-like 1
CST3 Gene for Cystatin
CTG Connective tissue graft
CTGF Connective tissue growth factor
CTLA-4 Cytotoxic T-lymphocyte-associated antigen 4
CYP-3A Cytochrome P450
DNA-PK DNA-dependent protein kinase
ECM Extracellular matrix
EGFR Epidermal growth factor receptor
ERK Extracellular signal-regulated kinase
FGF Fibroblast growth factor
GG Guanine guanine
GPx Glutathione peroxidase
GSTs Glutathione S-transferases
HBOT Hyperbaric oxygen therapy
HIF-1α Hypoxia-inducible factor-1α
HIF Hypoxia-inducible factor
HLA Human leukocyte antigen
HNSCC Head and neck squamous cell carcinoma
HPV Human papillomavirus
IFN Interferon
IGF Insulin-like growth factor
IL Interleukin
JAK Janus kinase
LIMK1 LIM domain kinase 1
LOH Loss of heterozygosity
LOX Lysyl oxidase
LOXL3 Lysyl oxidase-like 3
MAPK Mitogen-activated protein kinase
MEK Mitogen-activated protein kinase
MHC Major histocompatibility complex
MICA Major histocompatibility complex class I chain-related gene A
MMPs Matrix metalloproteinases
NFK Nuclear factor kappa
NQO1 NAD(P)H:quinone oxidoreductase 1
OPMDs Oral potential malignant disorders
OSCC Oral squamous cell carcinoma
OSF Oral submucous fibrosis
PAI-1 Plasminogen activator inhibitor-1
PCR Polymerase chain reaction
PDGF Platelet-derived growth factor
PIK3 Phosphoinositide 3-kinase inhibitor
PLOD2
Procollagen-lysine, 2-oxoglutarate 5-dioxygenase 2
RFLP Restriction fragment length polymorphism
ROS Reactive oxygen species
SAS Spindle assembly abnormal protein homolog
SMAD Small worm type, mothers against decapentaplegic
SNPs Single nucleotide polymorphisms
SOD Superoxide dismutase
Src Proto-oncogene c-Src
SSCP Single-strand conformation polymorphism
TGF Transforming growth factor
TGF-β Transforming growth factor-β
TGF-α Transforming growth factor-α
TIMPs Tissue inhibitors of matrix metalloproteinases
TNF Tumor necrosis factor
tPA Tissue plasminogen activator
TT Thymine thymine
uPA Urokinase plasminogen activator
VEGF Vascular endothelial growth factor
XRCC X-ray cross-complementing
αSMA Alpha smooth muscle actin
Contents
I Introduction to Oral Submucous Fibrosis
1 Oral Submucous Fibrosis:​A Historical Perspective
Vinay K. Hazarey and Newell W. Johnson
2 Epidemiology of Oral Submucous Fibrosis:​Prevalence and
Trends
Chandramani B. More and Deepa Jatti Patil
3 Clinical Features:​Oral Submucous Fibrosis
Saman Warnakulasuriya
4 Associated Conditions of Oral Submucous Fibrosis
A. Ramanathan and R. B. Zain
5 Oral Submucous Fibrosis in Childhood
Anura Ariyawardana
6 Classification Systems for Oral Submucous Fibrosis
Kannan Ranganathan and Kavitha Loganathan
7 Malignant Transformation of Oral Submucous Fibrosis
Omar Kujan and Majdy Idrees
II Aetiology of Oral Submucous Fibrosis
8 Lifestyle Factors
Yi-Hsin Connie Yang and Saman Warnakulasuriya
9 Genetic Aspects of Oral Submucous Fibrosis
Jay Gopal Ray and Rajiv S. Desai
10 Diet and Micronutrients
Madhura Murittige Gopalakrishna and Roopa S. Rao
III Aetiopathogenesis of Oral Submucous Fibrosis
11 In Vivo and In Vitro Experimental Evidence
Primali Jayasooriya and Upul Dissanayake
12 Fibrogenic Factors and Molecular Mechanisms
Paturu Kondaiah
IV Investigative Techniques for Oral Submucous Fibrosis
13 Noninvasive Diagnostic Techniques in Oral Submucous Fibrosis
Toru Nagao and Alexander Ross Kerr
14 Pathology of Oral Submucous Fibrosis
Kannan Ranganathan and Kavitha Loganathan
15 Biomarkers in Oral Submucous Fibrosis
Kannan Ranganathan and Kavitha Loganathan
V Management of Oral Submucous Fibrosis
16 Medical Management of Oral Submucous Fibrosis
Kavitha Loganathan and Kannan Ranganathan
17 Curcumin as a Chemopreventive Agent for Oral Submucous
Fibrosis
Sosmitha Girisa, Aviral Kumar and Ajaikumar B. Kunnumakkara
18 Surgical Management of Oral Submucous Fibrosis
Moni Abraham Kuriakose, Vijay Pillai and Pallavi Priyadarshini
VI Areca Nut Addiction and Treatment
19 Areca Nut Addiction:​Tools to Assess Addiction
K. A. L. A. Kuruppuarachchi and A. Hapangama
20 Behavioural Interventions for Areca Nut Cessation in the
Prevention and Management of Oral Submucous Fibrosis
Thaddeus A. Herzog and Neal A. Palafox
21 Pharmaceutical Agents for Areca Nut Cessation
Sumali Sumithrarachchi and Ruwan Jayasinghe
22 World Literature:​Bibliography
Radhika Manoj Bavle and P Sharada
Appendix:​Prominent Stalwarts in the Study of Oral Submucous
Fibrosis
Index
Contributors
Anura Ariyawardana
College of Medicine and Dentistry, James Cook University, Cairns,
Australia
School of Medicine and Dentistry, Griffith University, Gold Coast,
Australia
Metro South Oral Health, Logan Road Woolloongabba, Queensland,
Australia

Radhika Manoj Bavle

Department of Oral and Maxillofacial Pathology, Krishnadevaraya
College of Dental Sciences and Hospital, Bangalore, India

Rajiv S. Desai
Department of Oral Pathology and Microbiology, Nair Hospital Dental
College, Mumbai, Maharashtra, India

Upul Dissanayake
Department of Oral Pathology, Faculty of Dental Sciences, University of
Peradeniya, Peradeniya, Sri Lanka

Sosmitha Girisa
Cancer Biology Laboratory and DBT-AIST International Center for
Translational and Environmental Research (DAICENTER), Department
of Biosciences and Bioengineering, Indian Institute of Technology (IIT)
Guwahati, Guwahati, Assam, India

Madhura Murittige Gopalakrishna

Department of Oral Pathology and Microbiology, D A Pandu Memorial R
V Dental College, Bengaluru, Karnataka, India

A. Hapangama
Department of Psychiatry, University of Kelaniya, Kelaniya, Sri Lanka

Vinay K. Hazarey
Department of Oral Pathology, Datta Meghe Institute of Medical
Sciences, Wardha, Maharashtra, India
Thaddeus A. Herzog
Population Sciences Program, University of Hawaii Cancer Center,
Honolulu, HI, USA

Majdy Idrees
UWA Dental School, The University of Western Australia, Perth, WA,
Australia

Ruwan Jayasinghe
Department of Oral Medicine and Periodontology, Faculty of Dental
Sciences, University of Peradeniya, Peradeniya, Sri Lanka
Centre for Research in Oral Cancer, Faculty of Dental Sciences,
University of Peradeniya, Peradeniya, Sri Lanka

Primali Jayasooriya
Department of Oral Pathology, Faculty of Dental Sciences, University of
Peradeniya, Peradeniya, Sri Lanka

Newell W. Johnson
Menzies Health Institute Queensland, Griffith University, Gold Coast,
Australia

Kavitha Loganathan
Department of Oral and Maxillofacial Pathology, Ragas Dental College
and Hospital, The Tamil Nadu Dr. MGR Medical University, Chennai,
Tamil Nadu, India

Alexander Ross Kerr

Department of Oral and Maxillofacial Pathology, Radiology and
Medicine, New York University College of Dentistry, New York, NY, USA

Paturu Kondaiah
Department of Molecular Reproduction, Development and Gentics,
Indian Institute of Science, Bengaluru, Karnataka, India

Omar Kujan
Oral Pathology Dental School, The University of Western Australia,
Perth, WA, Australia
Aviral Kumar
Cancer Biology Laboratory and DBT-AIST International Center for
Translational and Environmental Research (DAICENTER), Department
of Biosciences and Bioengineering, Indian Institute of Technology (IIT)
Guwahati, Guwahati, Assam, India

Ajaikumar B. Kunnumakkara
Cancer Biology Laboratory and DBT-AIST International Center for
Translational and Environmental Research (DAICENTER), Department
of Biosciences and Bioengineering, Indian Institute of Technology (IIT)
Guwahati, Guwahati, Assam, India

Moni Abraham Kuriakose

Department of Head and Neck, Plastic and Reconstructive Surgery,
Roswell Park Cancer Institute, Buffalo, NY, USA
Karkinos Healthcare, Kochi, Kerala, India

K. A. L. A. Kuruppuarachchi
Department of Psychiatry, University of Kelaniya, Kelaniya, Sri Lanka

Chandramani B. More
Department of Oral Medicine and Radiology, K.M. Shah Dental College
and Hospital, Sumandeep Vidyapeeth, Vadodara, Gujarat, India

Toru Nagao
Department of Maxillofacial Surgery, School of Dentistry, Aichi Gakuin
University, Nagoya, Aichi, Japan

Neal A. Palafox
Department of Family Medicine and Community Health, University of
Hawaii, Honolulu, HI, USA

Deepa Jatti Patil

Department of Oral Medicine and Radiology, K.M. Shah Dental College
and Hospital, Sumandeep Vidyapeeth, Vadodara, Gujarat, India

Vijay Pillai
Head and Neck Surgery, Narayana Healthcity, Bengaluru, Karnataka,
India

Pallavi Priyadarshini
Head and Neck Surgery, Narayana Healthcity, Bengaluru, Karnataka,
India

A. Ramanathan
Department of Oral & Maxillofacial Clinical Sciences, Faculty of
Dentistry, University of Malaya, Kuala Lumpur, Malaysia

Kannan Ranganathan
Department of Oral and Maxillofacial Pathology, Ragas Dental College
and Hospital, The Tamil Nadu Dr. MGR Medical University, Chennai,
Tamil Nadu, India

Roopa S. Rao
Department of Oral Pathology and Microbiology Faculty of Dental
Sciences M S Ramaiah University of Applied Sciences, Bengaluru,
Karnataka, India

Jay Gopal Ray

Department of Oral Pathology, Dr. R Ahmed Dental College and
Hospital, Kolkata, West Bengal, India

P. Sharada
AECS Maaruti College of Dental Sciences and Research Center,
Bangalore, India

Sumali Sumithrarachchi
Centre for Research in Oral Cancer, Faculty of Dental Sciences,
University of Peradeniya, Peradeniya, Sri Lanka

Saman Warnakulasuriya
King’s College London, and the WHO Collaborating Centre for Oral
Cancer, London, UK

Yi-Hsin Connie Yang

National Institute of Cancer Research, National Health Research
Institutes, Tainan, Taiwan

R. B. Zain
Faculty of Dentistry, MAHSA University, Kuala Lumpur, Selangor,
Malaysia
Oral Cancer Research & Coordinating Centre, Faculty of Dentistry,
University of Malaya, Kuala Lumpur, Malaysia
I
Introduction to Oral Submucous
Fibrosis
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
S. Warnakulasuriya, K. Ranganathan (eds.), Oral Submucous Fibrosis, Textbooks in
Contemporary Dentistry
https://doi.org/10.1007/978-3-031-12855-4_1

1. Oral Submucous Fibrosis: A

Historical Perspective
Vinay K. Hazarey1 and Newell W. Johnson2
(1) Department of Oral Pathology, Datta Meghe Institute of Medical
Sciences, Wardha, Maharashtra, India
(2) Menzies Health Institute Queensland, Griffith University, Gold
Coast, Australia

Vinay K. Hazarey (Corresponding author)

Email: [email protected]

Newell W. Johnson
Email: [email protected]

1.1 Introduction
1.2 A Sweep Across Time
1.3 Other Relevant Ayurvedic Literature
1.4 Studies on OSF During the Past Century
1.4.1 Studies from South and SE Asia
1.5 Summary of Recent History
References

1.1 Introduction
Oral cancer has been a significant health issue in the Indian
subcontinent and contiguous geographical areas for centuries—
possibly for millennia. There are important references to this malady in
ancient scripts. In the last century, numerous researchers and clinical
groups have undertaken research on oral cancer using contemporary
concepts of scientific method and have also studied what were
described in the past as oral “precancers”: for these, we now use the
term oral potentially malignant disorders (OPMDs). Amongst the latter,
what is now labeled oral leukoplakia, with its variable definitions, has
received most attention. What we now call oral submucous fibrosis
(OSF) was, until around the middle of the last century, an entirely
enigmatic malady and received little attention. It was not until the
Indian otolaryngologists Joshi and De Sa from King Edward VII
Memorial (KEM) Hospital, Bombay (Mumbai, India), and the dentist Lal
from Central India documented their clinical observations in the 1950s
that real progress began to be made. The Basic Dental Research Unit of
the Tata Institute for Fundamental Research (TIFR) in Mumbai, India
conducted groundbreaking studies on OPMDs and oral cancer
throughout the 1960s and 1970s. These brought OSF to the forefront as
a critical OPMD in the Indian subcontinent. Thus, there began an
understanding of a relationship—potentially causal—with traditional
“betel quid” chewing habits, and we now know that it is predominantly
the areca nut component in the betel quid which is responsible for the
fibrosis. The early twentieth century contains interesting literature by
Bentall (1908) and Orr (1933) describing oral cancer in “betel”
chewers. Some of these cases had oral symptoms suggestive of OSF [1,
2] (► Box 1.1).

Box 1.1: Learning Objectives

1. To identify the historical documentation of OSF in South Asia.

2. To appreciate that associations made of OSF with chewing betel

quid in the early literature.

3. To correlate the early understanding and descriptions of OSF

from the Vedic and Modern era.
1.2 A Sweep Across Time
The Indian diaspora has distinguished itself throughout the world. East
Africa was one of the earliest countries where Indians migrated.
Wherever Indians went, they carried ethnic, cultural, and dietary habits
from home: local populations adopted the habits. As a result, the
twentieth- and twenty-first-century literature shows reports of OSF
studies from, for example, Taiwan, South Africa, Sri Lanka, Nepal, Guam
and China.
Areca nut consumption has been an integral part of the
sociocultural and religious milieu of India and surrounding countries
for millennia. Twentieth-century observations generated interest as to
whether betel quid, areca nut in particular, caused the tissue changes
seen in OSF—or at least similar signs and symptoms suggestive of the
presence of this disease in ancient times. We felt that scrutiny of
ancient Indian medical texts and related literature could reveal
interesting historical facts and contribute to understanding of
pathogenesis. Convincing contemporary evidence has implicated the
development of OSF to regular chewing of areca nut, although cases are
reported in children after quite short periods of use, as short as several
months. The practice of chewing betel quid or paan is ancient. Areca
nut and betel leaves are often used in Hindu religious and social
functions, as in the other major Eastern religions, Islam and Buddhism.
The first1 mention of betel quid dates back to 504 BCE (BC), recorded in
a Ceylon historical chronicle of events named “Mahavamsa,” written in
Pali [3]. Mentions of areca nut (Pugi Phalam) and betel leaf (Tambul)
consumption can also be found in the Sushruta1: Samhita2 of ~600 BCE
[4]. The Chikitsa3 Sthana4 of the Samhita highlights the benefits and
contraindications of Pugi Phalam and Tambul consumption in various
conditions. Shlokas 21–24 indicate that the chewing of Tambul, in
combination with many other ingredients, including areca nut, was
wholesome and beneficial for the oral cavity, throat, and face. However,
consumption of these mixtures in individuals with “intrinsic
hemorrhage, wasting due to chest wound, thirst, fainting, roughness,
debility, and mouth dryness” was not advocated. Thus, according to the
Sushruta Samhita, although betel leaf and areca nut are considered
sacred or beneficial, their use by individuals with dry mouth (as
observed in OSF) is contraindicated [4].
The Sushruta Samhita encompasses all aspects of human disease
prevalent in ancient India. The treatise made significant contributions
to the principles and techniques of ancient Indian surgery, which are
applicable even in the modern era [5]. The Royal Australasian College of
Surgeons (RACS) at its headquarters in Melbourne, Australia, has
stationed a statue of Sushruta as a mark of recognition and respect for
his contributions (◘ Fig. 1.1).
Fig. 1.1 Statue of Sushruta at the Royal Australasian College of Surgeons (RACS) in
Melbourne, Australia
 Many twentieth-century researchers, including Mukherjee and
Biswas (1972), appear to have compared OSF to a condition known as
“Vidari” in the Vedic literature [6]. According to them, the features of
Vidari, as mentioned in the Sushruta Samhita, were progressive
narrowing of the mouth, depigmentation of the oral mucosa, and pain
while taking food, which precisely fit the symptomatology of OSF as we
understand it today [6].
We conducted a thorough literature search on “Vidari” and
scrutinized six Sushruta Samhitas published or edited by the eminent
Indian Ayurvedic specialists Sharma, Patil, and Rajeshwari, amongst
others [7–13]. This search yielded the Sanskrit shloka “Sadahtodam
swayathum sarktamantrgale putivishirnsmasam/Pitten
Vidhyadwaden Vidarim parsve visheshat sat u yen shete” (Shloka
63). The English translation describes “a disease in which copper-
colored swelling occurs in the throat, featured by pricking and burning
sensation, and the flesh of the throat becomes necrosed and falls off and
emits a fetid smell.” The disease was regarded as of Pittaja origin and
was found to attack the side of the throat on which the patient is lying
[9]. The Samhita also describes this malady as an incurable disease and
recommends that the treatment of Vidari should be approached
without giving any assurance of cure [10]. Recently edited books on
Sushruta Samhita confirm the same [7, 13]. Several versions of Sushruta
Samhita describe Vidari as gangrenous stomatitis or “cancrum oris”
[12], although today we would recognize cancrum oris (Noma) as an
entity distinct from OSF [14]. According to Vidwansa, Vidari is
synonymous for carcinoma of tonsil and tonsillar fossa [11]. Vidari is
also translated as Pitika (eruptions) by Vagbhata [15].
Thus, according to Sushruta Samhita, Vidari is a throat disease
where copper-colored vesicles are the primary manifestations. The
description of Vidari mirrored that of gangrenous stomatitis,
peritonsillar abscess (quinsy), and carcinoma of the tonsil or tonsillar
fossa. Thus, our current understanding of the clinical presentations of
OSF is not in agreement with the traditional description of Vidari. In
our opinion, “Vidari” should not be used synonymously for OSF and
should be considered a misnomer.
1.3 Other Relevant Ayurvedic Literature
According to Ayurveda, diseases of the human body are grouped based
on three Doshas or principles, namely Vata (movement), Pitta
(transformation), and Kapha (lubrication and stability). Vagbhata (in
the first century CE (AD)) mentioned a condition with features similar
to those of OSF known as “vataja sarvasara” [15]. The shlokas
mentioned in his compilation are:
Karonti vadanasyaantvranan sarvasaro nilah/Saccharinorunan
rukshnoshto tamro chaltwachow (Shloka 66)

Jivha shitasaha gurvi sphutita kantakachita/Vivrunoti cha krichchhen

mukham pako mukhasya sah (Shloka 67)
Sloka 67 translates in English as “Anila (Vata)” aggravates and moving
in all directions produces ulcers inside the mouth, which are mild red in
color and dry (non-exudative); the lips are copper colored and
unsteady; the tongue is intolerant to cold and is heavy, cracked, and
covered with thorns; and the patient opens his mouth with difficulty
(“Vivrinoti cha Krichchhen Mukham” translated as “mouth opening with
difficulty”). This disease is Mukhapaka of vata origin [15].
Vidwansa described three pathological conditions that presented
with clinical features similar to OSF, namely Vataja Sarvasara—herpetic
gingivostomatitis/orolabial herpes; Pittaja Sarvasara with Raktaja
Sarvasara—aphthous ulcer/recurrent ulcerative stomatitis; and
Kaphaja Sarvasara—mild stomatitis [11].
Present-day Ayurveda deals with the management of conditions
with clinical features and pathogenesis similar to OSF based on the
individual’s prakriti and associated Dosha [16, 17]. Patel et al.
compared the clinical features of OSF with Dosha-based mukharogas
and proposed that OSF can be considered a Vata Pitta Pradhana
Sarvasara Mukhroga [16]. Recently, Patel and Patel, through their work
on the Ayurvedic management of OSF, emphasized that one cannot
directly equate OSF with any Mukhrogas in Ayurvedic classics; instead,
it should be considered as Anukta Vyadhi or an unexplained disease,
which may be managed by methodologies given by Acharya Charaka.
Studying the above Ayurvedic literature, some Sanskrit terms when
translated into English suggest similarities to the clinical symptoms of
OSF. These include Krichchhen Vivrinoti Mukham (difficulty in opening
mouth), Mukhadaha—Usha (burning sensation in mouth), Tishna Asaha
(intolerance to spicy food), Mukhsosha (dryness of mouth), Arasagyata,
Alparasagyata, Virasagyata (defective gustatory sensation),
Mukhantrargata Vrana (ulceration of oral mucosa), and Vranavastu,
Durudha Vrana (scar-fibrosis) [16, 17]. Thus, it seems probable that
OSF existed in the Sushruta or Vedic era (~800–900 BCE) (► Box 1.2).

Box 1.2: Appellations Used for Oral Submucous Fibrosis

Vedic Era:
Vidari—Sushruta Samhita (800 BCE) [Cited by Mukherjee& Biswas
(1972)]
Vataja Sarvasara—Waghbatta (first century CE (AD))

Modern Era:
Atrophica Idiopathica (Trophica) mucosae oris—Schwartz J (1952)
Submucous Fibrosis of Palate and Pillars—Joshi S (1953)
Diffuse Oral Submucous Fibrosis—Lal D (1953)
Idiopathic Scleroderma of the Mouth—Su I (1954)
Oral Submucous Fibrosis—Pindborg J. (1965)

1.4 Studies on OSF During the Past Century

OSF is common in India and elsewhere in South and SE Asia including
Sri Lanka, Micronesia, Indonesia, and the Philippines [18–23] (► Box
1.3, ◘ Maps 1.1 and 1.2, ◘ Table 1.1). Enclaves are found outside these
areas: in Africa, cases are being reported from Zanzibar, Tanzania,
Madagascar, Kenya, and South Africa, and in the United Kingdom
amongst the ethnic Indian diaspora. Because of modern travel, the use
of areca nut and cases of OSF are now found in many continents. Six
hundred million users are reported throughout the globe [23], ranking
areca nut to fourth place amongst addictive substances after tobacco,
alcohol, and caffeine [24, 25].
Map 1.1 Co-authorship data map on oral sub mucous fibrosis. Four or more articles
per author = 359 authors. 304 authors were connected
Map 1.2 Co-authorship map on oral submucous fibrosis-based geographic location
—5 or more articles per country = 25 countries; 24 are connected

Table 1.1 Co-authorship data on oral submucous fibrosis-based geographic location

Box 1.3: Bibliographic Data on Oral Submucous Fibrosis
Keyword search on “oral submucous fibrosis” undertaken in the
following databases on 8th November 2021:
– Web of Science: 1279 results
– Scopus: 1809 results
– Pubmed: 1638 results

1.4.1 Studies from South and SE Asia

1.4.1.1 India
OSF is an OPMD with an important historical background in India. As
summarized above, the earliest studies on OSF have their roots in
Bombay in the late 1940s and 1950s. The disease was studied by Joshi
and De Sa from around 1949 at the ENT Department of KEM Hospital,
Mumbai. However, almost all subsequent literature attributes the first
published reference to “idiopathica atrophica (trophica) mucosae oris”
by Schwartz, in five Indian Gujarati females from Kenya, with the habit
of chewing supari (areca nut). This was referenced as a
“demonstration” at the 11th International Dental Congress (of the
Federation Dentaire Internationale (FDI)), London, July 1952 [26]. This
reference has been quoted scores of times in subsequent literature, but
it is clearly quoted secondarily—without sight of the original. We
cannot locate original copy in spite of searches through libraries of
many institutions throughout the world and online. Quoting material
without sight of the original is bad practice.
Thus, the first detailed description of this disease in the modern era
should be attributed to Joshi in April 1953, who studied 41 cases from
Mumbai and called the condition “submucous fibrosis of palate and
pillars” [27]. Lal, an Indian dental graduate with licentiate
qualifications from the United Kingdom, working at the Govt. Medical
College, Gwalior (Central India), reported in May 1953 the
clinicopathological findings of 20 cases. All his cases had supari (areca
nut) chewing habits. He classified his cases into clinically early,
advanced, and extreme. He describes, in histological sections, diffuse
subepithelial fibrosis of the oral mucous membrane, with complete
replacement of normal lamina propria by dense acellular nonelastic
fibers, together with focal collections of lymphocytes and plasma cells.
He termed the disease “diffuse oral submucous fibrosis.” He suggested
physicochemical irritation or an allergen in supari (areca nut) as
causation and discussed the condition as a mucous membrane
counterpart of scleroderma [28]. There is, however, no subsequent
evidence of which we are aware that OSF occurs as part of a wider
fibrotic disease. Nevertheless, despite Lal’s probably erroneous linkage
to wider scleroderma, his original descriptions and attributes fit closely
to our present understanding of the disorder.
 Otolaryngologists in India studied the condition comprehensively
[27, 28]. Rao and Raju (1954) reported five cases, which had slowly
progressive incompetence to mouth opening associated with an
inability to eat food and which were treated using oral cortisone tablets
[29]. They described pallor of the oral mucosa and palpable, thick
vertical fibrous bands on both cheeks.
At KEM Hospital, Bombay, a detailed study of almost 100 cases was
undertaken. De Sa presented the investigations, treatment, and
outcomes of 64 cases in his 1957 publication [30]. The group there
performed extensive research exploring etio-pathological aspects and
relationships with other diseases and attempted to provide relief to
patients using then current concepts of treatment. They grouped cases
with predominantly palatal, faucial, and/or buccal involvement. They
described histopathological detail and sought to correlate this with
treatment outcomes. They concluded that “submucous fibrosis of the
palate and cheek” is a new connective tissue disorder with biological
similarity to the other collagen diseases but localized to the oral cavity.
These were noteworthy contributions for the time. George shared, in
1958, another report on treatment with cortisone injections [31].
Paymaster (1956) was the first to raise submucous fibrosis as a
“precancerous lesion.” Neoplasms of the oral cavity and pharynx
accounted for 45 percent of all malignancies seen in Indian patients at
the Tata Memorial Hospital, Mumbai, at that time—the 1950s [32].
Paymaster described mucosal melanin pigmentation and localized
submucosal fibrosis. He described clinical variations, treatment
approaches, and 5-year follow-up results of his cases. One-third of his
650 patients with “precancers” developed slow-growing carcinomas in
affected areas: another remarkable observation for the time [32].
Many early studies from India were conducted under the guidance
of the late, great Professor Jens Pindborg from Copenhagen, working
with several government dental colleges in North, Central, and South
India. Amongst these was the research conducted at a dental college in
Trivandrum, in which 40 out of 100 cases of oral cancer had clinical
signs of OSF [33].
Pindborg and Chawla examined 10,000 patients at the Dental
Department of King George’s Medical College in Lucknow, during
1964/1965 [34, 35]. All diagnoses were made on clinical grounds. Fifty-
one patients (1.48%) had OSF: 25 cases of OSF were found in a cohort
of patients seeking treatment in the clinics of dental colleges in
Lucknow [35]. A detailed demographic analysis of these OSF patients
contributed significantly to our understanding of initial and presenting
symptoms of OSF. In 7 cases, concomitant leukoplakia was observed in
patients with a history of tobacco abuse: this was the first report of
such an association [35].
In parallel, the TIFR, Mumbai, established itself as the central hub
for designing and executing epidemiological and translational studies
on oral cancer and “precancer.” Studies by Joshi, Lal, Sirsat, and
Pindborg between 1952 and 1964 led to the monumental
epidemiological surveys of the Basic Dental Research Unit of TIFR,
which began in 1966 and lasted almost 30 years. Professor Fali Mehta
was the principal investigator with Pindborg and Dr. James Hamner III
from the University of Tennessee, USA, was the National Institute of
Health (NIH) project officer—the studies were largely funded by the US
NIH. Dinesh Daftary (oral pathologist), Prakash Gupta (statistician),
Mira Aghi (behavioral scientist), and Ramesh Bhonsle, Paluri Ram
Murti, Pessi Sinor, Peshotan Jalnawalla, and Late Rohinton Irani
(dentists) formed the core team camping at rural areas in five districts
of different states and conducting oral examinations of close to two
hundred thousand people and coordinating with headquarters at TIFR
(► Box 1.4).

Box 1.4: Contributions from Tata Institute of Fundamental

Research (TIFR), Mumbai
Duration: 1966–1995
1. Pindborg et al.—1968
Epidemiological survey
Population studied: 50,915 individuals
Inference: Evidence in support of OSF as a “Precancerous
Condition”

2. Gupta et al.—1980
Observational study with 10 years follow-up
Inference: Association between tobacco and betel quid habits
and incidence of oral mucosal lesions.
 3. Murti et al.—1985
Observational study with 17 years follow-up of 66 individuals
with OSF
Malignant transformation rate studied over 10, 15 and 17
years (7.6%)

4. Bhonsle et al.—1987
A cohort of 64 and 24 OSF in a survey of 27,000 villagers in
Ernakulum and at Pune.
Regional variations and associations of areca nut habit with
OSF in Ernakulum and Pune

5. Murti et al.—1995
Review: The role of areca nut in the etiology of oral submucous
fibrosis.

A substantial literature was generated by the team, covering

prevalence, incidence, and natural history of a range of OPMD, including
OSF and outlining the development of malignancy, over more than a
decade of intensive study.
The Pindborg and Mehta 1968 paper presented epidemiological
surveys amongst Indian villagers. Amongst 50,915 persons studied,
OSF was more prevalent in South than in North India, the prevalence
ranging from 0% to 0.4%. Clinical data were analyzed from 63 cases of
OSF. Atrophy of tongue papillae was a prominent feature with a
prevalence of 60%. Heavy and frequent consumption of chilies was
often associated with the disorder, but chilies are an almost universal
component of South Asian food, and it is no longer thought that they
play a significant role in the pathogenesis of OSF. These findings did,
however, support OSF as a “precancerous” condition [36].
Simultaneously, many institutions in India and some overseas
instituted research on OSF. Those from India included the Government
Dental College and Hospital, Mumbai, and Nair Hospital Dental College,
Mumbai. Both these institutes started postgraduate courses in oral
pathology (then known as Dental Pathology and Bacteriology) in 1962–
1964. Mani was amongst the first to complete a Master’s dissertation at
the University of Bombay. In 1964–1966, under the supervision of
Singh, he evaluated 38 cases of OSF and published four papers in Indian
and international journals. Clinical and cytological aspects were
published in 1968 and 1976 [37, 38]. Subsequently, Mani and Singh
reported on the epithelial features of OSF and observed hyperkeratosis,
atrophy, increased mitoses, and glycogen in various grades of OSF. They
hypothesized that parakeratosis, increased mitosis, and atrophic
epithelium could indicate “premalignant change” and supported the
“precancerous” nature of OSF [39]. In 1977, Mani further compared the
connective tissue changes of OSF with those of collagen diseases like
scleroderma. They found inflammation and progressive collagen
deposition in the lamina propria with increasing clinical severity of the
condition [40]. These studies highlighted the need to explore whether
the epithelial-connective tissue changes occur concomitantly or as
independent responses to common irritants or other, still unknown,
factors implicated in the pathogenesis of OSF.
Akbar, a postgraduate student of Dholakia (who was the first
recognized postgraduate guide for “dental research” in India),
completed his dissertation, which focused on the clinical and
histopathological features of OSF in partial fulfillment of his Master’s
degree from the University of Bombay, 1964–1966. Amongst the 30
patients studied, he reported one elderly female with OSF and
concurrent scleroderma of the skin. The case showed extensive
involvement of the skin of legs, hands, chest, and face; the jaw deviated
to the left on opening. Subepithelial hyalinization was noted in 50% of
his oral biopsies [41, 42].
Renowned Indian cancer researcher and microbiologist, Sirsat, was
the first to employ electron microscopy to study OSF. She completed her
doctoral thesis entitled “Biological studies with the electron microscope
with special reference to submucous fibrosis of the palate” in 1958
from the University of Bombay [43]. Sirsat, in another collaboration
with Pindborg and Padma Bhushan awardee Khanolkar V, studied cases
of OSF and established a model in Wistar rats—the first ever animal
experiment on then condition (► Box 1.5).

Box 1.5: First Animal Model for OSF—Sirsat and Khanolkar

(1960, 1962)
 Study Animal: Wistar Rats
Features evaluated: Histological and Electron Microscopic
changes in collagen fibers of rat oral mucosa after treatment with
Capsiacin and Arecoline.

Sirsat and Khanolkar (1960) described histological and electron

microscopic features and studied the effect of trypsin, collagenases,
hyaluronidase, and elastase on the collagen fiber structure in their rat
model [44]. They studied the effects of arecoline and capsaicin on rat
oral mucosa and noted “elastic degeneration of collagen.” They
hypothesized that persistent mild injury over a prolonged period led to
fibrosis of the lamina propria [45–47].
Pindborg and Sirsat (1966) reviewed the etiological factors,
clinicopathological features, and potential treatment approaches [48].
They defined: “Oral submucous fibrosis is an insidious, chronic disease
affecting any part of the oral cavity and sometimes the pharynx. It is
occasionally preceded by a juxta-epithelial inflammatory reaction
followed by a fibroelastic change of lamina propria with epithelial
atrophy leading to stiffness of oral mucosa and trismus and inability to
eat.” They also described mast cell counts and vascular changes in both
early and advanced stages of OSF (1967) [49, 50]. They opined that
reduced vascularity was responsible for epithelial atrophy [50]. They
graded disease into very early, early, moderately advanced, and
advanced stages based on the histological features of edema, physical
state of collagen, fibroblastic response, vascularity, and number and
type of inflammatory cells present [51].
The TIFR team contributed to the understanding of prevalence and
incidence and of the timing and proportion of cases, which developed
oral cancer, and of the risk factors involved. In 1985, a population-based
house-to-house survey examined two lakh (2,00,000) Indian villagers.
This project delivered over 100 reports and expanded the knowledge of
tobacco and areca nut consumption practices prevalent in India, as well
as the pathogenesis of a range of OPMD and the risks of subsequent
malignancy.
Murti et al. (1985) followed up 66 cases of OSF for 17 years and
found that oral cancer developed in 0.4% of cases at the end of 10
years, in 4.5% at the end of 15 years, and in 7.6% at the end of 17 years
[52]. Gupta et al. (1980) reported a 10-year follow-up study, wherein
they quantified OSF, oral cancer, and other “precancerous lesions” in
Ernakulam, Bhavnagar, and Srikakulam. They associated social habits
with the prevalence and incidence of oral lesions: OSF did not occur
amongst those who did not practice chewing habits, nor in smoking-
only subjects [53].
The etiological role of chewing areca nut by itself was shown in a
study of regional variations of this condition in Ernakulam and Pune
districts of India by Bhonsle et al. (1987) [54]. This study showed that
part of the oral cavity most involved depends on the consumption
pattern, i.e., where the quid is customarily held and whether or not the
areca nut juice or quid is swallowed.
Hypotheses regarding the role of copper and the cuproprotein, lysyl
oxidase (LO), in the pathogenesis of OSF were generated by
collaborative work between researchers at King’s College London; the
Government Dental College, Nagpur; and the Department of Dental
Sciences at the Royal College of Surgeons of England. Trivedy et al.
(1997) proposed that copper in areca nut upregulates LO leading to
cross-linking of collagen and subsequent fibrosis [55]. They proposed
that oxidative deamination of lysine residues of collagen and elastin
fibers rendered them resistant to physiological degradation. Further,
considering the carcinogenic potential of OSF, Trivedy et al. (1998)
studied the immunoexpression and mutations of the p53 gene in OSF,
oral squamous cell carcinoma (OSCC) arising in OSF, and OSCC not
associated with OSF. In a large sample of OSF tissues collected from
Karachi, Pakistan, they proposed that the high copper content of areca
nut bound to p53 and inhibited its tumor suppressive properties [56].
They demonstrated that fibroblasts in OSF showed intense
immunoexpression of LO in the early stages of disease and in the
stroma surrounding invading epithelial islands in carcinomas arising in
OSF [57].

1.4.1.2 Sri Lanka

In early 1980s, Warnakulasuriya et al. conducted a large-scale oral
cancer and precancer screening program in Central Sri Lanka. Close to
30,000 adults aged over 20 years were screened by house-to-house
visit by primary healthcare workers. 4.2% of the subjects screened
positive, and amongst them 15 were reported with a OSF diagnosis
[58].

1.4.1.3 Taiwan
Su (1954) described reduced mouth opening in three Chinese men
from Taiwan aged 30–40 years who were “betel nut” chewers. The
author showed pale atrophic oral mucosa and limited tongue
movement. Microscopic examination of their oral mucosa revealed
fibrous “degeneration” of subepithelial layers. Su suggested the term
“stromal scleroderma” as the author found the condition similar to
systemic scleroderma and reported it with the title “idiopathic
scleroderma of the mouth” [59].
Thirty-five cases of OSF were studied by Shiau and Kwan from 1971
to 1976 in Taiwan. All patients had a history of one or more habits of
heavy liquor consumption, smoking, and/or “betel nut” chewing with a
strong correlation between habitual areca nut consumption and
occurrence of OSF [60].
In subsequent decades, Taiwanese scientists have made a significant
contribution to the field.

1.4.1.4 China
Apart from Taiwan, areca (betel) nut chewing was traditionally
practiced in Hainan Island of the People’s Republic of China. In 1983,
Pindborg surveyed 100 villagers with “betel nut” chewing habits and
habit/s of smoking cigarettes and water pipes. He reported three
women areca nut chewers with clinical and histologic changes of OSF
[61].
Areca nut chewing was also common in southeast provinces of
China. In Xiangtan, a big city of Hunan province, this habit can be traced
back to the beginning of the Qing dynasty. In Yuhu, one of the five urban
districts of Xiangtan city, 57 units independent of each other were
randomly selected for an epidemiological survey wherein 11,046
individuals were examined. OSF was found in 335 individuals (3.03%),
all of whom were areca nut chewers. OSF prevalence correlated to habit
duration [62].
1.4.1.5 Burma
The leaf of the Piper betel vine is called “Kun-yet” in Burmese. A quid
containing betel nut/areca nut and other ingredients is called “Kun-ya”
or simply “Kun.” Kun finds frequent mention in Burmese literature
emphasizing its religious and cultural importance with the tradition
dating back at least several hundred years. A marble inscription from
1248 AD refers to betel nut, revealing connections to royal regalia. A
host’s social status or official rank was ascertained based on the areca
nut type and quality he or she provided to his or her guests. A
comprehensive survey of 11 villages on the island of Bilugyun, Chuang-
zone township, Mon State of southeastern Burma, was carried out for
finding the prevalence of “oral precancerous lesions” and chewing and
smoking in which 6000 villagers above 15 years were examined. This
study, published in 1982, reported for the first time on five patients
with OSF from Burma [63].

1.4.1.6 Nepal
Nepal, sharing many cultural and dietary habits with the rest of South
Asia, has documented cases of OSF from as early as 1954. Lalchand
reported 15 cases during a 25-day stay in Nepal in 1954 [29].

1.4.1.7 Malaysia
An early contribution to OSF came from Malaysia by Krishnappa in
1967 [64]. Subsequently, Ramanathan (1981) observed iron-deficiency
anemia in 10 out of 13 OSF cases in Malaysia and hypothesized the
disease to be a form of sideropenic dysphagia [65]. All OSF patients
were of Indian ethnicity maintaining Indian dietary habits.

1.4.1.8 Papua New Guinea

Consumption of “betel nut” with betel “mustard” and lime is prevalent
in Papua New Guinea, but early literature only shows associations with
oral cancer [20]. The first documented case of OSF by Barnes and Duke
(1975) was in a Chinese woman residing in Papua New Guinea who had
no history of betel consumption [19]. Areca nut is known as buii in PNG.
Its use is ubiquitous. There are high rates of oral squamous cell
carcinomas [66], but no reports of OSF have been found after extensive
searches. We have this enigma under investigation.

1.4.1.9 South Africa

Consumption of areca nut was introduced into South Africa by Indian
immigrants in 1860 [67]. In what is now the Republic of South Africa,
there were soon about one million South Africans of Indian descent
concentrated mainly in Durban and environs. First amongst South
African studies are those by Shear and Lemmer in 1967 [68], who
found a prevalence of use of 0.5% amongst 1000 subjects of Indian
ethnicity.
Seedat worked extensively on the epidemiological aspects of OSF in
Durban, Natal, and submitted this work for his Ph.D. at Stellenbosch
University in 1985 [69].
In 1988, Seedat and Van Wyk conducted an epidemiologic survey of
2058 Indian subjects settled in South Africa and found 71 cases of OSF
—a remarkably high prevalence of 3.45% [70]. They revealed the
strong association with “betel nut” chewing. Women chewers
predominated with a ratio of 13:1. The habit was common in the
elderly, with 30.6% of women over 65 years being users. 38% of
chewers exhibited features of imminent or overt OSF, with female
predominance of 70:1. The majority (12.9%) of affected persons were
in the 45-54-year age group; 46% demonstrated fibrous bands in the
mouth. The investigators concluded that at that time 5% of the entire
Indian population in South Africa could be chewers, of which 2.3% may
develop OSF [70].
Seedat and van Wyk (1988) found typical clinical and
histopathological features of OSF in six non-betel nut-chewing subjects
raising the possibility of genetic predisposition and of other etiological
agents in Indian cultural practices [71]. They reported 14 cases of
ex-“betel nut” chewers with characteristic clinical and histological
features of OSF, which persisted even 13 years after stopping the habit
[72].
Van Wyk (1997) reviewed OSF amongst South Africans of Indian
origin and found that the betel quid use was more common amongst
women. 60% of chewers preferred a betel quid with other “classical”
ingredients, while others consumed only nut. Most chewers preferred
the baked (black) nut variety, and few added tobacco to their chew. This
pattern was reflected in the distribution of OSF. Their OSF subjects
were younger with shorter chewing histories compared to chewers
without OSF [73].

1.5 Summary of Recent History

In the later decades of the previous century, there have been numerous
reviews on OSF describing epidemiology and pathogenesis [74, 75].
Pindborg et al. [36] assembled the early information on OSF (◘ Table
1.2) according to geographic location, gender, and age.
In 1978, a working group of the WHO defined OSF as a “probable
precancerous” condition, along with leukoplakia [76]. In 2005, the
WHO Collaborating Center for Oral Cancer and Precancer at King’s
College London recommended the term “oral potentially malignant
disorders,” which included OSF [77]. This list, and definitions of OPMDs,
has recently been updated [78].
Table 1.2 Distribution of OSF by geographic location, sex, and age in early
investigations (1952–1964) [34]

Investigator Year Country Cases Percentage The age

women range in
years
Schwartz 1952 East Africa 5 100 –
(Indians)
Lal 1953 India (Madhya 20 – –
Pradesh)
Joshi 1953 India 41 54 10–60
(Bombay)
Su 1954 Taiwan 3 0 30–40
Rao and Raju 1954 India 7 86 18–40
(Lalchand in Nepal 15 – –
discussion to Rao and
Raju)
De Sa 1957 India 64 53 10–55
Investigator Year Country Cases Percentage The age
women range in
years
Sharan 1959 India 21 Males 12–62
predominated
Rao 1962 India 46 63 12-64
(Hyderabad)
1962 India 85 53 10–58
(Bombay)
Pindborg 1964 India 25 60 Female: 22–
(Lucknow) 65
Average:
33.7 years
Male: 40–70
Average:
53.6 years

Summary
Evolution of OSF from Vedic to early modern-day literature.
Correlation of dosha/prakruti-based diseases in Ayurveda with OSF.
Early research from South Asian countries and their contributions
pertaining to etiology, clinical, histological as well as electron
microscopic features of OSF.
Contemporaries—Joshi, De Sa and Lal described OSF in 1952–53
under different terms, to the evolution of existing knowledge of what is
now known as OSF.

Acknowledgements
We thank the following for their enthusiastic support in literature
searching, especially in accessing ancient publications:
Dr. Supriya Kheur, Professor and Head, Department of Oral
Pathology and Microbiology, Dr. D.Y. Patil Dental College and Hospital,
Dr. D.Y. Patil Vidyapeeth, Pune, India.
Dr. Karishma M Desai, Assistant Professor, Department of Oral
Pathology and Microbiology, Dr. D.Y. Patil Dental College and Hospital,
Dr. D.Y. Patil Vidyapeeth, Pune, India.
Another random document with
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 OREN

Prunus americana

1. Ia. Sta. Bul. 46:285 fig. 1900. 2. Waugh Plum Cult. 174. 1901. 3.
Budd-Hansen Am. Hort. Man. 299. 1903.
 Bartlett 1. Bingaman 1.

Waugh places Oren with the “Miner-like” plums but as the variety
grows here it is a typical western Americana—the characters of this
species in leaf, fruit and stone being well shown in the
accompanying plate. It is one of the best of the Americanas in both
fruit and tree. The fruits are large and of good shape, perhaps a little
dull in color and not quite as good in quality as a few other
Americanas but still averaging very well in all fruit-characters. The
flesh is very nearly free from the stone. The trees are typical of the
species, shaggy of trunk and limb, straggling and unkempt in growth
of top, but hardy, robust, healthy and reliable in bearing. It would
seem as if this variety is rather too good to be allowed to pass out of
cultivation until there are more Americanas that are better.
Oren was taken from the wild in Black Hawk County, Iowa, about
1878, by J. K. Oren. Mr. Oren grew trees of this plum on his farm
and permitted all who came to take sprouts, cions and seed until the
variety was very generally disseminated locally. Who introduced it to
the trade and when is not known.

Tree small, spreading, low, dense-topped, hardy, often unproductive;

branches roughish, slightly zigzag, thorny, dark ash-brown, with small
lenticels; branchlets slender, long, twiggy, with internodes of average
length, green changing to dark chestnut-brown, glabrous, with large,
conspicuous, raised lenticels; leaf-buds small, short, obtuse, free.
Leaves falling early, oval or obovate, two inches wide, three and three-
quarters inches long; upper surface dark green changing to golden-yellow
late in the season, smooth and shining, with a narrow, grooved midrib;
lower surface silvery-green, lightly pubescent; apex taper-pointed, base
abrupt, margin coarsely serrate, the serrations ending in sharp points,
eglandular; petiole five-eighths inch long, thick, tinged red, thinly
pubescent, glandless or with one or two prominent, greenish-brown
glands.
Blooming season late and of medium length; flowers appearing after the
leaves, one and one-eighth inches across, white; borne in clusters on
lateral spurs and buds, in pairs or in threes; pedicels five-eighths inch
long, slender, glabrous, green, tinged with red; calyx-tube red,
campanulate, enlarged at the base, glabrous; calyx-lobes narrow,
somewhat obtuse, pubescent on both surfaces and on the margin,
reflexed; petals ovate, somewhat crenate or fringed, tapering below to
long, narrow claws, sparingly hairy along the edge of the base; anthers
yellow; filaments three-eighths inch long; pistil glabrous, shorter than the
stamens.
Fruit intermediate in time and length of ripening season; one and three-
sixteenths inches in diameter, roundish, usually truncate and slightly
oblique, compressed, halves equal; cavity very shallow, flaring; suture a
line; apex roundish or flattened; color dull light or dark red over a yellow
ground, mottled, with thick bloom; dots numerous, very small, light russet,
inconspicuous; stem slender, five-eighths inch long, glabrous; skin tough,
astringent, adhering; flesh dark golden-yellow, juicy, fibrous, soft and
melting, sweet; fair to good; stone semi-free, seven-eighths inch by five-
eighths inch in size, irregularly roundish or ovate, flattened, blunt at the
base and apex, with smooth surfaces; ventral suture strongly winged;
dorsal suture acute, with a narrow and shallow groove.

ORLEANS
Prunus domestica

1. Quintinye Com. Gard. 68. 1699. 2. Langley Pomona 91, Pl. XX fig. 4.
1729. 3. Miller Gard. Dict. 3:1754. 4. Duhamel Trait. Arb. Fr. 2:78, Pl. VII.
1768. 5. Knoop Fructologie 2:52, 55, 56, 57. 1771. 6. Forsyth Treat. Fr.
Trees 19. 1803. 7. Kraft Pom. Aust. 2:32, Tab. 179 fig. 1. 1796. 8.
Brookshaw Pom. Brit. Pl. XI. 1817. 9. Lond. Hort. Soc. Cat. 145, 150.
1831. 10. Prince Pom. Man. 2:62, 67, 85. 1832. 11. Poiteau Pom. Franc.
1:1846. 12. Floy-Lindley Guide Orch. Gard. 289, 290, 383. 1846. 13.
Thomas Am. Fruit Cult. 339. 1849. 14. Elliott Fr. Book 428. 1854. 15.
Thompson Gard. Ass’t 519. 1859. 16. Downing Fr Trees Am. 935. 1869.
17. Mas Pom. Gen. 2:37, fig. 19. 1873. 18. Am. Pom. Soc. Cat. 36. 1875.
19. Oberdieck Deut. Obst. Sort. 414. 1881. 20. Mathieu Nom. Pom. 435.
1882. 21. Hogg Fruit Man. 715. 1884. 22. Guide Prat. 156, 360. 1895.
Anglaise Noire 16, 17, 20, 21, 22. Angloise Noire 5. Brignole? 1.
Brugnole? 1. Brignole Violette 17, 20, 22. Brignole Violette? 5. Common
Orleans 10, 16, 17, 20. Damas Rouge 10. Damas Rouge 5, 9. Damas
Violet? 5. De Monsieur 17, 22. Die Herrnpflaume 7. English Orleans 10,
16, 17, 20. French Orleans 8. Hernnpflaume 17. Herrnpflaume 19.
Herrnpflaume 22. Herzog von Orleans 20, 22. Italian Damask of some 14.
Large Red Orleans 10. Late Monsieur 10, 16, 17, 20. Monsieur 4, 9, 10,
 12, 17, 22. Monsieur 10, 13, 14, 15, 16, 20, 21. Monsieur Ordinaire 9, 10,
14, 15, 16, 17, 20, 21, 22. Old Orleans 10, 13, 14, 15, 16, 17, 20, 22.
Orleans 17, 20, 22. Orleans Red Damask 20. Prune de Monsieur 10, 16,
20. Prune de Monsieur 11. Prune d’Orleans 16, 17, 20, 21. Prunelle? 5.
Prune Monsieur 7. Red Damask 10. Red Damask 9, 10, 12, 13, 14, 15,
16, 17, 18, 20, 21, 22. Red Orleans 10, 16, 17, 20. Red Orleans Plum 6.

In Europe Orleans is one of the most renowned of the plums

cultivated. A proof of its popularity is the great number of names, as
shown in the synonymy given above, under which it passes in
England and on the continent. This variety, however, is almost
unknown in America though described by all of the older American
pomologists and probably introduced time and again during the last
hundred years in our orchards. The French fruit books say that the
variety thrives better in southern than northern France and nearly all
of the European writers state that it does best in high, dry, light,
warm soils. It is likely that our climate, and the soils in which plums
are generally grown in America, are not suited to this sort.
Unfortunately this Station has no trees of this variety and the brief
description given is a compilation.
The Orleans has been cultivated for more than two hundred years.
Langley said of it in 1729 “The Orleans Plumb tho a common, is yet
a very valuable Plumb, as well for its fine firm juicy Pulp when well
ripened, as its being a constant and plentiful bearer.” The Red
Damask and the Brugnole mentioned by Quintinye in 1699 are
probably the Orleans; but the Prune de Monsieur of Knoop and the
Monsieur of Tournefort, which are yellow, are distinct. The variety is
evidently of French origin. Mas in his Pomologie Generale, 1873,
states that it first bore the name Brignole Violette, but later was given
the name it now bears in honor of Monsieur, Duke of Orleans,
brother of Louis XIV. Damas Rouge is an old synonym, though
Duhamel described it as a distinct variety. Herrnpflaume is the
common name of the Orleans in Germany and Austria, while in
France, it is often called the Monsieur. It has never been common in
America, yet it was entered on the American Pomological Society
catalog list in 1875.
 Tree large, vigorous, hardy, productive, bearing annually; branches
grayish, pubescent; leaves large, ovate, with crenate margins; flowers
large, blooming early; petals roundish, imbricated.
Fruit early mid-season; medium in size, roundish-truncate, sides
unequal; cavity usually shallow, wide; suture distinct; apex flattened; color
dark or purplish-red, overspread with thin bloom, with a sprinkling of pale
reddish dots; stem thick, short; skin tender; flesh yellowish, juicy, usually
melting when properly matured, sweet near the skin but sprightly toward
the center, pleasant-flavored; good; stone free, small, oval, flattened, with
roughish surfaces.

OULLINS
 OULLINS

Prunus domestica

1. Hogg Fruit Man. 374. 1866. 2. Downing Fr. Trees Am. 935. 1869. 3.
Pom. France 7: No. 15. 1871. 4. Mas Le Verger 6:43. 1866-73. 5. Am.
Pom. Soc. Cat. 38. 1877. 6. Cat. Cong. Pom. France 366. 1887. 7.
 Mathieu Nom. Pom. 446. 1889. 8. Waugh Plum Cult. 117. 1901. 9.
Thompson Gard. Ass’t 4:158. 1901.
Massot 6, 7. Monstrueuse d’Oullins 2, 7. Ouillin’s Gage 2, 7. Oullins
Golden 1. Oullin’s Golden 2, 9. Oullin’s Golden 3, 4, 6, 7. Oullin’s Golden
Gage 2, 7. Oullins Golden Gage 5. Oullin’s Green Gage 8. Prune-Massot
3. Reine-Claude d’Oullins 1, 2, 7, 9. Reine-Claude D’Oullins 3, 4, 6.
Reine-Claude Prêcoce 1, 2, 3, 6, 7, 9. Reine-Claude von Oullins 7. Roi-
Claude 3, 7.

Oullins came to America with the best of recommendations from

European growers but it has fallen so far short of its reputation in
Europe that it was dropped from the fruit list of the American
Pomological Society and is gradually disappearing from cultivation.
The fault is in the fruit which is but indifferent in quality for a plum of
the Reine Claude group. In Europe the variety is rated as one of the
best dessert sorts; in America it is hardly second-rate in quality. This
difference may be due to differences in climate and soil; more
probably, it is due to the greater number of better Reine Claude
varieties grown in America with which it must compete. Hand,
Jefferson, Washington, McLaughlin, Yellow Gage, Spaulding and
Imperial Gage, the cream of the Reine Claude plums, are all
Americans similar to Oullins but much better in quality. Oullins is
hardly surpassed by any of its group in tree-characters and might
well be used for breeding purposes as there are so few sorts of its
kind having satisfactory trees.
This variety, probably a Reine Claude seedling, was found at
Coligny, France, on the estate of M. Filliaud; it was propagated by M.
Corsaint, gardener to the Baron de Toisy, near Cuiseaux
(Department of Saone-et-Loire) and was introduced at Oullins
(Department of Rhone) by M. Massot, nurseryman. The name is
seldom spelled correctly in American fruit books, being either written
with an apostrophe and s or with both left off, these spellings coming
from the supposition that the name comes from that of a man, a
mistake as the history shows. Oullins was placed on the American
Pomological Society catalog fruit list in 1875 but was dropped when
the catalog was revised in 1897.
 Tree large, vigorous, spreading, open-topped, hardy, productive;
branches ash-gray, somewhat rough, with numerous, large, raised
lenticels; branchlets stout, the bark rough, medium to above in thickness,
short, with short internodes, greenish-red changing to brownish-red, dull,
lightly pubescent, overspread with faint bloom, with numerous, small
lenticels; leaf-buds large, long, pointed, free; leaf-scars swollen.
Leaves oval or obovate, two inches wide, four and one-quarter inches
long, thick; upper surface dark green, covered with fine hairs, the midrib
grooved; lower surface pale green, pubescent; apex acute or abruptly
pointed, base acute, margin serrate or crenate, with small black glands;
petiole three-quarters inch long, thick, pubescent, tinged red, with from
two to four globose, greenish-brown glands variable in size, usually on the
stalk.
Blooming season medium to late, of average length; flowers appearing
after the leaves, one and one-quarter inches across, white, with a faint
yellowish tinge; arranged on lateral spurs, singly or in pairs; pedicels
eleven-sixteenths inch long, pubescent, greenish; calyx-tube green,
campanulate, pubescent; calyx-lobes broad, obtuse, pubescent on both
surfaces, glandular-serrate, reflexed; petals broadly obovate, crenate,
tapering to short, broad claws; anthers yellowish; filaments three-eighths
inch long; pistil glabrous, equal to the stamens in length.
Fruit early, season short; medium to below in size, roundish, halves
equal; cavity shallow, below medium in width, abrupt; suture an indistinct
line; apex flattened or depressed; color greenish-yellow changing to dull
light yellow, overspread with thin bloom; dots numerous, small, whitish,
inconspicuous, clustered about the apex; stem of medium thickness and
length, adhering well to the fruit; skin thin, slightly astringent, separating
readily; flesh greenish-yellow or pale yellow, somewhat dry, firm, sweet,
not high in flavor; good; stone half-free or free, three-quarters inch by five-
eighths inch in size, broadly oval, flattened, roughened and pitted, blunt at
the base and apex; ventral suture rather narrow, furrowed, with a distinct
but not prominent wing; dorsal suture broadly and deeply grooved.

PACIFIC
 PACIFIC

Prunus domestica

1. U. S. D. A. Rpt. 292. 1893. 2. Am. Pom. Soc. Rpt. 150. 1895. 3.

Oregon Sta. Bul. 45:31. 1897. 4. Oregon Hort. Soc. Rpt. 474. 1898. 5. Am.
 Pom. Soc. Cat. 40. 1899. 6. Waugh Plum Cult. 117. 1901. 7. Oregon
Agriculturist 17: No. 24, 370. 1908.
Pacific 3. Pacific Prune 2, 3. Willamette 4, 5, 7. Willamette Prune 3.

No part of America is so well adapted to plum culture as the

Pacific Coast and especially the inter-mountain valleys in Oregon.
From the last-named State, though fruit-growing is a very recent
development, a number of meritorious plums have been added to
pomology. One of the best of these, as they grow in New York, is the
Pacific, the fruits of which are well shown in the color-plate. Few
purple plums are more beautiful than this in color and shape, few
equal it in size and very few of its color excel it in quality. The trees
are unusually robust, perfectly hardy and productive. In Oregon the
Pacific has not proved a good prune-making plum but is reported as
standing eastern shipment very well, which, if true, indicates that this
plum would succeed as a market fruit in New York. Pacific is well
worth trying in New York as a commercial variety.
This plum is hopelessly confused with the Willamette. The
following is an abridged account of the two fruits as written us by H.
M. Williamson, Secretary of the Oregon State Board of Horticulture,
and one of the leading authorities on fruit-growing on the Pacific
Coast.

“About 1875 Jesse Bullock of Oswego, Oregon, sent to Germany for

pits of the Italian or Fellenberg prune, and planted the pits received in a
nursery row. When the trees from these began to bear, Mr. C. E. Hoskins
went to Mr. Bullock’s place, examined the fruit and selected trees which
seemed promising, giving to each tree a number. From at least six of
these trees he took scions, propagated them, and named them Bullock
No. 1, Bullock No. 2, etc. He finally decided that only two of these, Bullock
No. 1 and Bullock No. 6, were of sufficient value to justify their further
propagation. Bullock No. 1 was named Champion and Bullock No. 6,
Willamette. Mr. Hoskins told me these names were given by the State
Horticultural Society, but I find no record of this action. He propagated and
sold a good many trees of both varieties, but more of the Willamette than
of the Champion.
“Mr. Hoskins was strongly of the opinion that the Pacific is identical with
the Willamette. I am as strongly of the opinion that they are distinct
 varieties. I base my opinion, first, upon the history of the origin of the
Pacific given me by Henry Freeboro, Portland, Oregon, who introduced it;
and, second, upon what appear to me to be marked differences in the two
prunes. A number of years ago I went to Mr. Freeboro’s place when
prunes were ripe and obtained from him a supply of Pacific prunes grown
on trees propagated by him from scions taken from the original Pacific
tree. I took these prunes to Springbrook and compared them with the
Willamette grown on Mr. Hoskins’ place. I was thoroughly convinced that
the two were decidedly different in character, but Mr. Hoskins did not think
so. I noticed first a marked difference in the habits of growth of the trees.
The Pacific trees were of unusually vigorous growth and had a decided
upright tendency. The Willamette trees were very similar to the Italian in
vigor and had the rather spreading habit of growth of the Italian. The
Pacific prunes are larger in size than the Willamette and vary much more
in size. One of the most decided indications of difference is the far greater
tendency to brown-rot of the fruit of the Pacific than is the case with the
fruit of the Willamette. This has been observed when scions of the
Willamette and of the Pacific have been grafted on the same tree for the
purpose of comparison. I have never seen a well dried specimen of the
Pacific, but this may have been the fault of the men who dried the
specimens I have seen. The Willamette dries easily for a prune of its size
and gives a larger percentage of dried to fresh fruit than the Italian,
according to Mr. Hoskins.
“I believe the Willamette is well worthy of more attention in the
Willamette Valley, whereas the Pacific, on account of its extreme
susceptibility to the brown-rot, does not appear to be a safe variety here,
although when perfect it is a magnificent prune for eating fresh, and one of
the very largest known. I am told that in eastern Oregon where climatic
conditions keep out the brown-rot, the Pacific is proving one of the best
varieties for shipping fresh. At the present time the two varieties are much
confused. When the Pacific prune was introduced, Mr. Hoskins and other
recognized authorities, pronounced it the Willamette, and nurserymen
therefore obtained scions from Willamette trees and sold the propagated
trees as Pacifies, and in a more limited way the reverse was done. The
greater part of the trees supposed to be Pacifics are in fact Willamettes.”

At this Station we have the two plums under discussion, the

Pacific having been obtained from Fred E. Young, nurseryman,
Rochester, New York, and the Willamette, under the name Pacific,
from the Oregon Wholesale Nursery Company, Salem, Oregon. The
differences between the two plums in New York are essentially those
given by Mr. Williamson as distinguishing characters in Oregon.

Tree of medium size, upright-spreading, open-topped, hardy, productive;

branches ash-gray, smooth, with small, raised lenticels; branchlets above
medium in thickness, short, with short internodes, greenish-red changing
to brownish-red, covered with heavy bloom and sparingly pubescent, with
indistinct small lenticels; leaf-buds plump, of medium size and length,
obtuse, free.
Leaves obovate, two inches wide, four inches long, the oldest thick and
leathery; upper surface dark green, covered with fine hairs, with a widely
and deeply grooved midrib; lower surface pale green, pubescent; apex
acute or obtuse, base acute, margin crenate, with small dark glands;
petiole seven-eighths inch long, thick, pubescent, tinged red, with from two
to four large, globose, yellowish-green glands usually on the stalk.
Blooming season of medium length; flowers appearing after the leaves,
one and three-sixteenths inches across, white; borne on lateral spurs and
buds, singly or in pairs; pedicels five-sixteenths inch long, thick,
pubescent; calyx-tube green, campanulate, pubescent only at the base;
calyx-lobes broad, obtuse, lightly pubescent on both surfaces but heavily
pubescent along the serrate margin, reflexed; petals oval, dentate,
tapering to short, broad claws; stamens inclined to develop into
rudimentary petals; anthers yellow; filaments seven-sixteenths inch long;
pistil glabrous, equal to the stamens in length.
Fruit intermediate in time and length of ripening season; two inches by
one and five-eighths inches in size, ovate, halves equal; cavity shallow,
narrow, flaring; suture shallow, indistinct; apex bluntly pointed; color bluish,
overspread with thick bloom; dots small, brown, conspicuous, clustered
about the apex; stem thick, one-half inch long, pubescent, adhering well to
the fruit; skin thin, tough, separating readily; flesh pale golden-yellow,
juicy, firm, sweet, spicy; good; stone free, one inch by five-eighths inch in
size, flattened, irregularly broad-oval, obliquely contracted at the base,
blunt at the apex, with rough and pitted surfaces; ventral suture narrow,
with numerous deep furrows, usually blunt; dorsal suture widely and
deeply grooved.

PALATINE
Prunus domestica
 This plum, scarcely known outside of two counties in New York, is
of distinctly good quality and if all accounts are true is fairly immune
to black-knot. In size and appearance the fruits are superior to many
other Reine Claude plums, with which it must be compared, so much
so that the variety is probably worth growing outside the region
where the following interesting history shows it has been cultivated
for nearly a century and a half.
Palatine, according to Mr. Washington Garlock of New York,
originated in 1760 when a family of Palatines by the name of Best
came from Germany to the United States and settled in Livingston
Manor (East Camps) now Columbia County, New York. They brought
with them plum pits which they planted and from them secured one
tree. In 1762 they moved to Schoharie County, New York, taking with
them the seedling tree. In their new home they propagated the
variety, which they named Palatine, and disseminated it so
industriously that it became thoroughly established throughout
Montgomery and Schoharie counties and attained great popularity
because of its apparent freedom from black-knot. That this popularity
is merited is attested by the fact that after one hundred and fifty
years it is still extensively grown in that vicinity.
 Tree large, vigorous, spreading, dense-topped, productive; branches
thick; branchlets lightly pubescent; leaves flattened, slightly drooping,
obovate, one and five-eighths inches wide, three and one-quarter inches
long, thick, rugose; margin coarsely crenate, eglandular or with few, small
glands; petiole pubescent, glandless or with one or two small glands;
blooming season intermediate in time, short; flowers appearing after the
leaves, more than one inch across, white with yellow tinge at the apex of
the petals; borne singly; calyx-lobes thickly pubescent on both surfaces,
strongly reflexed.
Fruit intermediate in time and length of ripening season; about one and
one-half inches in diameter, roundish or roundish-oval, dull yellowish-
green becoming greenish-yellow at full maturity, mottled and indistinctly
blushed on the sunny side, overspread with thin bloom; skin thin, slightly
sour; flesh light golden-yellow, juicy, fibrous, firm, sweet, pleasant in flavor;
good to very good; stone dark colored, free or nearly so, seven-eighths
inch by one-half inch in size, oval, with thickly pitted surfaces; ventral
suture blunt or with a short, narrow wing; dorsal suture wide, shallow.

PAUL EARLY
Prunus domestica

1. N. Y. Exp. Sta. Rpt. 12:611. 1893. 2. W. N. Y. Hort. Soc. Rpt. 42:83.

1897.
Paul’s Earliest 1, 2.

This variety seems to be under test only at this Station where it

has fruited for a number of years. It is so similar to Early Rivers, a
variety of small account in America, as to be an almost worthless
addition to the list of plums. Paul Early originated with and was sent
out by J. M. Paul, North Adams, Massachusetts, about 1888.

Tree very large, vigorous, round-topped, dense, very productive;

branches covered with numerous fruit-spurs; branchlets twiggy, thickly
pubescent; leaf-buds strongly appressed; leaves flattened, obovate or
oval, two and three-eighths inches wide, four inches long; margin crenate,
with few, small, dark glands; petiole reddish, pubescent, glandless or with
one or two large glands; blooming season intermediate in time, short;
 flowers appearing before the leaves, one inch across; borne in scattering
clusters, usually in pairs; pedicels very thick and pubescent; anthers
tinged red.
Fruit very early, season short; one and three-eighths inches by one and
one-quarter inches in size, roundish-oval, dark purplish-black, overspread
with thick bloom; skin tender, slightly sour; flesh greenish-yellow becoming
yellowish, tender, sweet near the surface but sour next the pit, mild; good;
stone clinging, seven-eighths inch by five-eighths inch in size, irregular-
oval, with roughened and thickly pitted surfaces; ventral suture prominent,
seldom winged; dorsal suture with a narrow, shallow groove.

PEACH
Prunus domestica

1. N. E. Farmer Dict. 266. 1797. 2. Prince Treat. Hort. 27. 1828. 3.

Prince Pom. Man. 2:106. 1832. 4. Downing Fr. Trees Am. 307. 1845. 5.
Horticulturist 1:113, 114 fig. 34, 147. 1846. 6. Poiteau Pom. Franc. 1:1846.
7. Thomas Am. Fruit Cult. 335, 336 fig. 262. 1849. 8. Horticulturist 6:132.
1851. 9. Elliott Fr. Book 422. 1854. 10. Downing Fr. Trees Am. 367. 1857.
11. Hooper W. Fr. Book 250. 1857. 12. Am. Pom. Soc. Cat. 86. 1862. 13.
Hogg Fruit Man. 375. 1866. 14. Mas Le Verger 6:73. Pl. XXXVII. 1866-73.
15. Pom. France 7: No. 7. 1871. 16. Gard. Chron. N. S. 17:144. 1882. 17.
Mich. Hort. Soc. Rpt. 466. 1883. 18. Wickson Cal. Fruits 353. 1891. 19.
Wash. Hort. Soc. Rpt. 136. 1893. 20. Guide Prat. 156, 361. 1895. 21. Cat.
Cong. Pom. France 462 fig. 1906.
Apricot Plum 5 incor. Caledonian 15, 20. Calvels Pfirschenpflaume 14,
20. D’Abricot (of Streets of Paris) 20. Duane’s Purple 5 incor, 6, 11.
Howells Large 15, 20, 21. Jenkin’s Imperial 15, 20. Large Peach 16. Large
Peach Plum 3. Nectarine 15, 20. Nectarine Rouge 21. Peach 15, 20.
Peach Plum 3, 5, 14, 20. Peach Plum 7, 8, 9, 10, 11, 12, 17. Pêche 14,
15, 20, 21. Pêche de Calvel 20. Prune Pêche 3, 7, 9, 10, 14, 18. Prune
Pêche 4, 5, 6, 20. Prune-Pêche De Calvel 14. Reine-Claude De Berger
13, 16. Rothe Nektarine 15, ?20.

Peach, the largest early plum, is not high in quality but is justly
esteemed where it can be grown for its earliness, large size and
handsome appearance. Unfortunately this variety is capricious
beyond most other plums as to climate and soils and refuses to
thrive unless its needs are very well supplied in the matter of
environment. In America it seems to find congenial soil and climate
only on the Pacific Coast, and even then refuses to bear well except
on strong, rich soils. In New York, even when grown upon soils
similar to those upon which it does well elsewhere, the fruits are few
and lacking in quality, though the trees are large, vigorous and about
all that could be desired in a good plum tree. It may be possible to
grow Peach in favorable locations in the East; in which case, a plum
of its appearance and quality, coming as early in the season as it
ripens, would make a most desirable addition to the list of plums.
From its behavior elsewhere the situation that would suit it best in
New York is a sunny exposure with a warm, rich, clay loam.
The origin of the Peach is unknown. Poiteau was unable to find
any reference to it in the Eighteenth Century European literature and
thought, therefore, that it must have been unknown to this period.
Samuel Deane mentions a Peach plum in New England in 1797. It is
doubtful, however, whether it is the Peach of this discussion, the
name having been applied indiscriminately to several varieties, the
Goliath, Nectarine and Apricot in particular. Prince, in 1832,
described a Large Peach Plum which he said “had been introduced
a few years since” but as his variety is oval and a clingstone, it is not
the same as the Peach of Poiteau, the one discussed here, this plum
being nearly round and a freestone. Judge James C. Duane of
Schenectady, New York, seems to have first imported the Peach
plum, with several others, from France, in 1820. The name of this
variety was lost during the shipment and as the invoice called for an
Apricot Plum, the names Apricot and Duane’s Plum became locally
applied to what afterwards turned out to be the Peach. C. H.
Tomlinson of Schenectady and A. J. Downing in 1846 made a careful
study of these imported plums and showed conclusively that this
Apricot or Duane’s Plum was the Peach of the French. In 1862, the
American Pomological Society added Peach to the fruit catalog list
and recommended it for the eastern and western sections of New
York.

Tree large, very vigorous, spreading, round or flat-topped, hardy,

medium in productiveness; branches stocky, smooth, dark ash-brown, with
lenticels of medium number and size; branchlets thick, with internodes one
inch long, light brown, covered with short, heavy pubescence; leaf-buds
large, of medium length, conical.
Leaves large, oval, of average thickness; upper surface dark green;
lower surface pale green, pubescent; apex obtuse, margin doubly crenate,
with small glands; petiole three-quarters inch long, thick, pubescent, with a
trace of red, usually with two, small, globose, greenish glands at the base
of the leaf.
Fruit early; thick-set, without a neck, one and seven-eighths inches in
diameter, roundish, slightly angular, halves equal; cavity deep, wide,
compressed; suture shallow, distinct; apex flattened or depressed; color
dark purplish-red, overspread with thin bloom; dots numerous, large,
conspicuous; stem eleven-sixteenths inch long, glabrous, adhering well to
the fruit; skin tough, adhering; flesh golden-yellow, medium juicy, firm,
subacid, mild; good; stone free, one inch by three-quarters inch in size,
roundish-oval, flattened, with rough and pitted surfaces, blunt at the base
and apex; ventral suture wide, prominent, often distinctly winged; dorsal
suture with a wide, deep groove.

PEARL
 PEARL

Prunus domestica

1. Burbank Cat. 5. 1898. 2. Am. Gard. 21:36. 1900. 3. Waugh Plum

Cult. 118. 1901.
 One can grow seedlings of some plums with considerable
certainty of getting respectable offspring—plums worth having in an
orchard—but the chances of growing a variety of superior qualities
are small indeed. It is a piece of good luck, a matter almost wholly of
luck, when, as in this case, but one parent is known, to secure as
fine a fruit as the Pearl plum. The variety now under notice is one to
be pleased with if it came as a chance out of thousands; its rich,
golden color, large size, fine form, melting flesh and sweet, luscious
flavor, place it among the best dessert plums. In the mind of the
writer and of those who have assisted in describing the varieties for
The Plums of New York, it is unsurpassed in quality by any other
plum. The tree-characters, however, do not correspond in desirability
with those of the fruits. The trees, while of medium size and
seemingly as vigorous and healthy as any, are unproductive. In none
of the several years they have been fruiting at this Station have they
borne a large crop. If elsewhere this defect does not show, the
variety becomes at once one of great value. The fruits of Pearl are
said to cure into delicious prunes—to be readily believed by one who
has eaten the fresh fruits. This variety ought to be very generally
tried by commercial plum-growers and is recommended to all who
grow fruit for pleasure.
Pearl is a recent addition to the list of plums and though its history
is well known its parentage is in doubt. In 1898, Luther Burbank
introduced the variety as a new prune grown from the seed of the
well-known Agen. The male parent is not known but from the fruit
and tree, one at once surmises that it was some variety of the Reine
Claude group, its characters being so like those of the plum named
that no one could suspect that it came from the seed of a plum so far
removed from the Reine Claude as the Agen.

Tree of medium size, vigorous, vasiform, dense-topped, hardy,

unproductive; branches ash-gray, with numerous, small, raised lenticels;
branchlets twiggy, thick, long, with long internodes, greenish-red changing
to brownish-red, very pubescent early in the season becoming less so at
maturity, with numerous, small, raised lenticels; leaf-buds large, above
medium in length, conical, appressed; leaf-scars prominent.
 Leaves broadly oval, one and seven-eighths inches wide, three and
one-half inches long, thick, leathery; upper surface dark green, rugose,
covered with fine hairs, with a grooved midrib; lower surface pale green,
pubescent; apex abruptly pointed, base abrupt, margin serrate or crenate,
with small, black glands; petiole seven-eighths inch long, thick, pubescent,
tinged red, glandless or with from one to three small, globose, brownish
glands on the stalk.
Blooming season intermediate in time and length; flowers appearing
after the leaves, showy on account of their size, averaging one and five-
eighths inches across, white, with a tinge of yellow at the apex of the
petals; borne on lateral spurs and buds, usually singly; pedicels one-half
inch long, thick, strongly pubescent, greenish; calyx-tube green,
campanulate, pubescent; calyx-lobes broad, obtuse, pubescent on both
surfaces, glandular-serrate and with marginal hairs, strongly reflexed;
petals obovate or oblong, entire, tapering to short, broad claws; anthers
yellow; filaments nearly one-half inch long; pistil glabrous, shorter than the
stamens.
Fruit intermediate in time and length of ripening season; one and three-
quarters inches by one and one-half inches in size, roundish-oval,
compressed, halves unequal; cavity shallow, narrow, abrupt; suture a line;
apex depressed; color golden-yellow, obscurely striped and splashed with
dull green, mottled, overspread with thin bloom; dots numerous, small,
whitish, inconspicuous, clustered about the apex; stem thick, three-
quarters inch long, thickly pubescent, adhering well to the fruit; skin tough,
separating readily; flesh deep yellow, juicy, a little coarse and fibrous, firm
but tender, very sweet, with a pleasant, mild flavor, aromatic; very good to
best; stone clinging, one inch by five-eighths inch in size, long-oval,
slightly necked at the base, bluntly acute at the apex, with rough surfaces;
ventral suture broad, blunt; dorsal suture with a wide, shallow groove.

PETERS