|Year : 2008 | Volume
| Issue : 4 | Page : 135-140
Levamisole and antioxidants in the management of oral submucous fibrosis: A comparative study
Vasanti Jirge, MC Shashikanth, IM Ali, Nisheeth Anshumalee
Department of Oral Medicine and Radiology, College of Dental Sciences, Davangere-577 004, India
|Date of Web Publication||18-Jun-2009|
Department of Oral Medicine and Radiology, KLE VK Institute of Dental Sciences, Belgaum 590 006
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background and Objectives: Oral submucous fibrosis (OSMF) is a chronic condition of the oral cavity which results in permanent disability. The pathogenesis is poorly understood and the disease is difficult to treat. OSMF is associated with immunological changes (altered levels of serum immunoglobulins) and the effect of treatment (especially antioxidants and levamisole) on serum immunoglobulins (Ig) is not known. This study was carried out to evaluate the clinical effects of levamisole (VERMISOL), and antioxidants (ANTOXID) and its effect on serum immunoglobulins IgG, IgA and IgM. Meterials and Methods: Forty-five study subjects were included in the study. Patients were randomly assigned into three groups. There were 15 patients in each group; group I patients received levamisole, 50 mg three times daily for three alternate weeks, group II patients received 2 capsules of antoxid daily for six weeks, group III patients received levamisole and antoxid. The results were analyzed with paired 't' test and unpaired 't' test. Results: The results indicated that levamisole, antoxid and the combination of levamisole and antoxid showed significant improvement in mouth opening and reduction in burning sensation. Significant reduction of serum IgG, IgA and IgM was seen in the levamisole group and combination group whereas in the antoxid group significant reduction was observed only in serum IgA and IgM. Interpretation and Conclusion: Levamisole can bring about clinical improvement and is better than antoxid and the combination regimen. The addition of antoxid to the treatment regimen does not seem to have an added advantage over levamisole alone.
Keywords: Antoxid, immunoglobulins, levamisole, oral submucous fibrosis
|How to cite this article:|
Jirge V, Shashikanth M C, Ali I M, Anshumalee N. Levamisole and antioxidants in the management of oral submucous fibrosis: A comparative study. J Indian Acad Oral Med Radiol 2008;20:135-40
|How to cite this URL:|
Jirge V, Shashikanth M C, Ali I M, Anshumalee N. Levamisole and antioxidants in the management of oral submucous fibrosis: A comparative study. J Indian Acad Oral Med Radiol [serial online] 2008 [cited 2019 Jul 20];20:135-40. Available from: http://www.jiaomr.in/text.asp?2008/20/4/135/52827
| Introduction|| |
Oral submucous fibrosis is a chronic disease of insidious onset featuring the deposition of fibrous tissue in the submucous layer of the palate, fauces, cheek, lips, pharynx and esophagus. The underlying muscles of mastication may be affected resulting in trismus and disability.  Oral submucous fibrosis was earlier considered to be a disease of the Indian subcontinent, where as many as 5 million sufferers have been reported.  However, immigration has created a worldwide distribution. A few cases have been reported in other races. The condition has been shown to be precancerous and carries a high relative risk for malignant transformation. 
Over the years, attention has been paid to immunologic changes associated with oral submucous fibrosis. There have been conflicting reports regarding the levels of serum immunoglobulins in patients with oral submucous fibrosis with one or more of them being elevated. ,,,
To date there is no report suggesting spontaneous regression and no widely accepted treatment. The following approaches have been tried, namely nutritional supplements, intralesional injections of placental extracts, corticosteroids, hyaluronidase and chymotrypsin, antioxidants and surgical excision of fibrotic bands with placement of grafts. ,,,,,
After reviewing current literature, it was noticed that the effect of immunomodulators like levamisole has not been adequately explored in the treatment of oral submucous fibrosis. Hence this study was undertaken to compare the efficacy of levamisole with antioxidants (ANTOXID) and to evaluate the levels of serum immunoglobulins (IgG, IgM, IgA) before and after treatment.
| Methodology|| |
The present randomized, single blind study was conducted in the Department of Oral Medicine and Radiology, Department of Oral Pathology, College of Dental Sciences, Davangere and Department of Microbiology, Maratha Mandal Dental College, Belgaum. The study group comprised 45 OSMF patients of either sex above 15 years of age. Diagnosis of OSMF was made on the basis of natural history and characteristic clinical features which included the presence of burning sensation in the mouth, intolerance to spicy food, blanching and loss of suppleness of oral mucosa, presence of palpable fibrous bands and decreased mouth opening. All cases were confirmed histopathologically and were divided clinically into stages as per the criteria described by Haider et al .  Patients who were apparently healthy and well oriented in time, space and as a person, patients who satisfied the characteristic clinical features of OSMF with histopathologic confirmation and had burning sensation, patients who were not taking any medication for their disease condition, patients who agreed to the biopsy, blood and immunological examination and patients who were willing for follow-up visits, and those who were willing to quit the habit of chewing areca nut/ gutkha/ and tobacco in any form were included in the study.
Patients with OSMF and any past or present systemic diseases (e.g. diabetes, hypertension, liver disorders or kidney diseases, autoimmune disorders), other mucosal lesions, patients suffering from acute or chronic infection, patients with a known allergy or contraindication to the study drugs were excluded from the study.
The drugs used were levamisole (50 mg tablets, trade name - Vermisol, manufacturing company: Khandelwal Laboratories), antioxidant capsules (Trade name: ANTOXID - Contents: beta carotene -10 mg, zinc sulphate monohydrate -27.5 mg, selenium dioxide -70 mg, manganese -2 mg, copper -1 mg, manufacturing company: Dr. Reddy's Laboratories Ltd.)
Based on inclusion and exclusion criteria 45 study subjects were included in the study. All the participants were explained the need for and design of the study. The benefits of undergoing a thorough clinical examination, biopsy and blood investigation were made known to these potential participants. Ethical clearance was obtained from the Institutional Review Board. Only those patients who gave a signed informed consent on an institutionally approved document participated in the study. For immunological investigations, 5 ml of blood was drawn from the ante-cubital fossa. The blood was allowed to clot and the serum obtained was stored at 4°C until it was used for radial immunodiffusion. Serum IgG, IgA and IgM were estimated by Serial Radial Immunodiffusion (SRI). This procedure was performed after treatment also.
Patients were randomly divided into three groups. All patients received their first treatment dose one week after biopsy was performed. Patients were recalled at weekly intervals for six weeks, and then at an interval of thirty days for the next two months. At each visit patients were evaluated and administered the subsequent dose. Group I patients took 1 tablet of levamisole 50 mg, three times daily, for three consecutive days in a week for three alternate weeks, group II patients took one capsule of antoxid two times daily for six weeks, group III patients took 1 tablet of levamisole 50 mg, three times daily, for three consecutive days in a week for three alternate weeks and one capsule of antoxid two times daily for six weeks.
The interincisal mouth opening was measured using divider and scale from the mesio-incisal angle of upper central incisor to the mesio-incisal angle of lower central incisor and recorded in millimeters. The intensity of burning sensation was determined using a Visual Analogue Scale (VAS) of 0-100 with 10 mm division, where 0 is no burning sensation and 100 is the worst possible burning sensation. The patients were asked to mark the VAS at a point which best represented the burning sensation at that visit.
Post treatment follow-up involved the evaluation of the patient once in 30 days over a period of the next 60 days. Post treatment serum immunoglobulin estimation was carried out one month after completing treatment. All the relevant data collected was entered in a pro forma. Demographic data, physical examination data and laboratory data so gathered were sorted, tabulated and subjected to appropriate statistical analysis.
Descriptive data that included mean, numbers and percentages were calculated for each group and were used for analysis. Paired 't' test was used for intra group comparison, and unpaired 't' test was used for inter group comparison using the SPSS package (10 th version). For all the tests, a p-value of 0.05 or less was considered for statistical significance.
| Results|| |
At the end of treatment the improvement in mouth opening [Table 1],[Graph 1- [Additional file 1] ] in patients treated with levamisole (group I) was 7.1%, in group II 6.7% and in group III 8%. At the end of the two-month follow-up period the improvement in mouth opening in group I was 10.7%. In groups II and III the improvement remained the same (6.7 and 8% respectively). No statistically significant difference was found between the three groups.
Statistically highly significant reduction in burning sensation was seen in all the three groups. Inter group comparisons did not reveal statistically significant differences [Table 2],[Graph 2 - [Additional file 2] ].
Significant reduction was seen in the serum IgG, IgA and IgM [Table 3],[Graph 3 - [Additional file 3] ] in the levamisole group (14.8, 28.1, 28% respectively) and the combination group (13.4, 21.9, 18.3% respectively) which was statistically significant (p < 0.001), while in the antoxid group significant reduction was seen in serum IgA and IgM (17, 26.8% respectively). The reduction in mean serum IgG was significantly better in the levamisole group (group I) and the levamisole and antoxid combination group (group III) than in the antoxid group (group II) [group I v/s group II ( P < 0.01) and group III v/s group I ( P <0.01)]. The intergroup comparison for reduction in serum IgA and IgM was not statistically significant.
| Discussion|| |
To date OSMF is poorly understood and unsatisfactorily treated. Based on clinical, epidemiological and in vitro studies, areca nut chewing is considered an important predisposing factor. As is the case with oral cancer and most of its precursor lesions, the etiology of OSMF is multifactorial. Various methods have been tried to bring relief from burning sensation, and to decrease fibrous bands, and improve mouth opening. These include intralesional injections of corticosteroids, placental extracts or hyaluronidase either alone or in combination, intralesional injections of IFN γ, micronutrient supplementation, physiotherapy, and surgery. ,,,,,
Levamisole is an immunomodulator which modifies both cellular and humoral immunity.  This property has been made use of in treatment of several oral mucosal lesions with successful results. However its effects on OSMF are not known. ANTOXID is an antioxidant formulation that contains beta carotene, zinc, copper, manganese and selenium. It has been found that these micronutrients have antioxidant properties and enhance cellular immunity. The serum levels of beta carotene have found to be significantly reduced in OSMF patients and supplementation with BC was associated with clinical improvement and increase in serum BC levels as well. 
It has been found that some of the serum immunoglobulins are elevated in OSMF patients; ,,, however it is not known whether it can decrease after treatment with levamisole and antioxidants. The present study was thus conducted to treat OSMF patients with levamisole, antoxid or a combination of the two and to estimate the serum level of IgG, IgA, and IgM before and after treatment in all the patients. There are no reported randomized clinical trials of levamisole in the treatment of OSMF. In our study the patients were administered 50 mg levamisole thrice a day for three consecutive days for three alternate weeks. The regimen for antoxid group was two capsules per day, each day for six consecutive weeks.
Restriction of mouth opening is a major disability associated with OSMF. To date there is no treatment protocol that can restore the mouth opening to normal, but an improvement of a few millimeters has been seen. In our study a highly significant improvement was seen in all the three groups and the improvement was better in the levamisole and antoxid combination group i.e., 8% (group III), when compared to 7.1% in the levamisole (group I) and 6.7% in the antoxid (group II) groups. However at the end of follow-up it was seen that the mouth opening continued to improve in patients who had taken levamisole alone (group I) i.e. 10.7%, but the differences among the groups were not statistically significant. The distribution of samples was not uniform across the three groups. While the lowest mouth opening was 2.2 cm in group I, it was 1.5 cm in group?. The more severe the restriction in mouth opening, the longer it takes to regain some improvement, therefore the significant result is probably masked by an improper sample distribution.
Until now no published studies have evaluated the clinical efficacy of levamisole in OSMF patients, hence the findings associated with levamisole cannot be directly compared with any other study. However studies have been done using antioxidant supplements and have shown better results compared to our study, probably because higher doses of micronutrients were used. Gupta et al . reported a 50% improvement in mouth opening in 6 of their patients treated with antoxid.  Maher et al .  also reported an improvement of 17.9% in mouth opening in their OSMF patients after being treated with micronutrient and mineral supplementation. However 10% of their patients reported worsening of mouth opening after treatment. Zinc is one of the constituents of ANTOXID and has antioxidant properties. Kumar et al.  have reported significant improvement in mouth opening with oral zinc therapy. However in all these studies, the doses used were higher and the duration of treatment was longer than in our study.
Though intralesional injections with different drugs have shown better improvement in mouth opening, they are associated with significant discomfort, pain and infection at the injection site and reduction in mouth opening over a longer follow up period. ,, Therefore our treatment regimen may be safer. However, the long-term prognosis cannot be assessed, as the follow-up period was short in our study.
Burning sensation when eating spicy food or even normal food is common among OSMF patients due to which they switch over to bland diet, which is generally not nutritionally adequate. Although the exact mechanism causing burning sensation is not clear, intolerance to spices could be due to the atrophic and permeable epithelium. In our study, patients treated with levamisole (group I) had a reduction in burning sensation by 98% at the end of treatment and 98.6% at the end of the follow up period. Patients treated with antoxid (group II) had 82.4% reduction at the end of treatment and 86.7% reduction after the follow-up period. Patients who were treated with the combination of levamisole and antoxid (group III) had a 93.1% reduction at the end of treatment and 96.7% reduction at the end of the follow-up period. Maher et al . have also reported similar findings.  In their study multiple micronutrient supplements produced relief from burning sensation in 85% of the patients. Treatment of OSMF with intralesional injections of hyaluronidase and/or corticosteroids (dexamethasone or triamcinolone acetonide) has been reported to reduce burning sensation by 75-100%. Treatment with intralesional placental extracts  and IFN γ have resulted in reduction in burning sensation by 40-51% and 60% respectively. The patients in our study showed reduction in burning sensation comparable to that seen in patients treated with intralesional injections of hyaluronidase and/or corticosteroids and better than that in patients treated with intralesional placental extracts and IFNγ. Since our treatment was non invasive and not associated with side effects as in intralesional injections, we can expect better patient compliance and consequently better results. Though the reduction in burning sensation was sustained in all the three groups, levamisole alone seems to be more effective when compared to antoxid or combination of levamisole and antoxid. There were no statistically significant differences between the groups. The relief from burning sensation in patients treated with levamisole is probably due to the anti inflammatory effects of levamisole and its ability to modulate inflammatory cytokines. 
The reduction in mean serum IgG and IgA was better in the levamisole group (group I) and the levamisole and antoxid combination group (group III) than in the antoxid group (group II) but the reduction was significant only for IgG. The reduction in mean serum IgM was better in the levamisole group (group I) and the antoxid group (group II) than in the levamisole and antoxid combination group (group III) but the difference was not statistically significant. OSMF is associated with altered immunoglobulin profile. Various studies have reported an increase in one or more of the five immunoglobulins in OSMF patients. ,,, There have been no reports in which serum immunoglobulins IgG, IgA, IgM were evaluated before and after treatment of OSMF with levamisole or antioxidants.
Levamisole has been found to modulate both cellular and humoral immunity in patients with recurrent aphthous ulcers and chronic hepatitis. , These reports are similar to the findings in our study. The reductions in the levels of IgG, IgA and IgM as seen in our study suggest that the humoral response in OSMF is modified, probably due to slowing down of the chronic inflammatory process. It has been shown that beta carotene not only has antioxidant properties but also improves cellular immunity by increasing the number of circulating lymphocytes and number of helper T cells, enhancing the proliferation and induction of cytotoxic T cells, and enabling natural killer cells to be more effective on supplementation in those who are beta carotene deficient.  The reduction in serum IgG, IgA and IgM due to antioxidants in our study is probably secondary to reduction in inflammation. None of the patients in our study reported any side effects due to study drugs.
From our study, it can be inferred that levamisole is better than antoxid in improving mouth opening and decreasing burning sensation and levamisole alone may be given to patients with OSMF. Addition of antoxid does not seem to have an added advantage in the treatment of OSMF. Further studies on a larger sample size with longer follow-up periods are required to know the exact mechanism of action of levamisole and antioxidants in OSMF.
| Conclusion|| |
Based on the clinical examination and statistical analysis of the data collected, the following conclusions could be drawn: Treatment of OSMF with levamisole, antoxid and the combination produced statistically significant improvement in mouth opening and reduction in burning sensation. Levamisole and combination of levamisole and antoxid produced statistically significant reduction in IgG, IgA and IgM, while antoxid produced significant reduction in IgA and IgM. The reduction of IgG by levamisole and combination of levamisole and antoxid was significantly better than that by antoxid alone. Overall, better response was seen to levamisole alone, than to antoxid and combination therapy.
The present study involved a small sample size in a dental setting. Thus the results of our study need to be confirmed involving a large population of OSMF patients treated for a longer time. Further research can be directed at evaluating the effects of levamisole and antoxid on the serum levels of fibrogenic and anti fibrotic cytokines, and on the rate of malignant transformation in OSMF patients after treatment with levamisole or antioxidants.
| References|| |
|1.||Gupta S, Reddi MV, Harinath BC. Role of oxidative stress and antioxidants in etiopathogenesis and management of oral submucous fibrosis. Indian J Clin Biochem 2004;19:138-14. |
|2.||Rajalalitha P, Vali S. Molecular pathogenesis of oral submucous fibrosis: A collagen metabolic disorder. J Oral Pathol Med 2005;34:321-8. |
|3.||Rajendran R, Sugathan CK, Remani P, Ankathil R, Vijaykumar T. Cell mediated and humoral responses in oral submucous fibrosis. Cancer 1986;58:2628-31. |
|4.||Gupta DS, Gupta M, Oswal RH. Estimation of major immunoglobulin profile in oral submucous fibrosis by radial immunodiffusion. Int J Oral Surg 1985;14:533-7. |
|5.||Chaturvedi VN, Marathe NG. Serum globulins and immunoglobulins in oral submucous fibrosis. Indian Practitioner 1988;41:399-403. |
|6.||Shah N, Kumar R, Shah MK. Immunological studies in oral submucous fibrosis. Indian J Dent Res 1994 t;5:81-87. |
|7.||Canniff JP, Harvey W, Harris M. Oral submucous fibrosis: Its pathogenesis and management. Br Dent J 1986;21:429-34. |
|8.||Maher R, Aga P, Johnson NW, Shankarnarayanan R, Warnakulasuriya S. Evaluation of multiple micronutrient supplementation in the management of oral submucous fibrosis in Karachi, Pakistan. Nutr Cancer 1997;27:41-73. |
|9.||Kumar A, Sharma SC, Sharma P, Chandra O, Singhal KC, Nagar A. Beneficial effect of oral zinc in the treatment of oral submucous fibrosis. Indian J Pharmacol 1991;23:236-41. |
|10.||Haque MF, Meghji S, Nazir R, Harris M. Interferon gamma (IFN-γ) may reverse oral submucous fibrosis. J Oral Pathol Med 2001;30:12-21. |
|11.||Lai DR, Chen HR, Lin LM, Huang YL, Tsai CC. Clinical evaluation of different treatment methods for oral submucous fibrosis: A 10-year experience with 150-cases. J Oral Pathol Med 1995;240:402-6. |
|12.||Gupta D, Sharma SC. Oral submucous fibrosis: A new treatment regimen. Oral Maxillofac Surg 1988;46:830-3. |
|13.||Katharia SK, Singh SP, Kulshreshtha VK. The effects of placenta extract in the management of oral submucous fibrosis. Indian J Pharmacol 1992;24:81-3. |
|14.||Sun A, Chiang CP, Chiou PS, Wang T, Liu BY, Wu YC. Immunomodulation by levamisole in patients with recurrent aphthous stomatitis ulcers or oral lichen planus. J Oral Pathol Med 1994;23:172-7. |
|15.||Haider SM, Merchant AR, Fikree FF, Rahban MH. Clinical and functional staging of oral submucous fibrosis. Brit J Oral Maxillofac Surg 2000;38:12-5. |
|16.||Sun A, Wang JT, Chia JS, Chiang CP. Levamisole can modulate the serum tumor necrosis factor-α in patients with recurrent aphthous ulcerations. J Oral Pathol Med 2006;35:111-6. |
|17.||Demirci F, Bayraktaroglu Z, Karaoglan M, Coskun Y, Karaoglan I, Okan V. Immunomodulatory effects of HBsAg vaccine and levamisole in chronic hepatitis and hepatitis B carrier children. Turk J Gastroenterol 2005;16:188-93. |
|18.||Kaugars GE, Silverman S, Lovas JG, Thompson JS, Brandt RB, Singh VN. Use of antioxidant supplements in the treatment of human oral leukoplakia. Oral Surg Oral Med Oral Pathol 1996;81:5-13. |
[Table 1], [Table 2], [Table 3]