|Year : 2014 | Volume
| Issue : 3 | Page : 260-263
Evaluation of efficacy of turmeric in management of oral submucous fibrosis
Nitin Agarwal, Devika Singh, Abhishek Sinha, Sunita Srivastava, Ruchika K Prasad, Govind Singh
Department of Oral Medicine and Radiology, Sardar Patel Post Graduate Institute of Dental and Medical Sciences, Lucknow, Uttar Pradesh, India
|Date of Submission||06-Sep-2014|
|Date of Acceptance||01-Nov-2014|
|Date of Web Publication||19-Nov-2014|
Professor and Head, Department of Oral Medicine and Radiology, Sardar Patel Post Graduate Institute of Dental and Medical Sciences, Raebareily Road, Lucknow, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Aim: The aim of this study was to evaluate the efficacy of turmeric in oral submucous fibrosis (OSMF) patients. Objectives: To check the treatment efficacy of turmeric in terms of burning sensation on Visual Analog Scale (VAS) and mouth opening, and to evaluate the group which showed the maximum improvement. Materials and Methods: 30 subjects diagnosed with OSMF were included in this study. The patients were administered commercially available turmeric; their mouth opening and burning sensation on VAS scale were evaluated at regular intervals, and the data was then compared. Results: The improvement in mouth opening was not significant; however, the change in burning sensation on VAS was significant. Conclusion: Treatment of OSMF with turmeric is an affordable and effective treatment methodology; however, further research needs to be done.
Keywords: Oral submucous fibrosis, turmeric, visual analog scale
|How to cite this article:|
Agarwal N, Singh D, Sinha A, Srivastava S, Prasad RK, Singh G. Evaluation of efficacy of turmeric in management of oral submucous fibrosis
. J Indian Acad Oral Med Radiol 2014;26:260-3
|How to cite this URL:|
Agarwal N, Singh D, Sinha A, Srivastava S, Prasad RK, Singh G. Evaluation of efficacy of turmeric in management of oral submucous fibrosis
. J Indian Acad Oral Med Radiol [serial online] 2014 [cited 2019 Mar 24];26:260-3. Available from: http://www.jiaomr.in/text.asp?2014/26/3/260/144998
| Introduction|| |
First mentioned in the early 1950s, oral submucous fibrosis (OSMF) is a potentially malignant condition with characteristic features of stiffness of mucosa and restricted mouth opening caused by changes in fibers of the connective tissue and deeper parts. It is a condition most primarily seen in people of Asian descent.  The earliest and rarest sign includes formation of vesicles, accompanied by a juxtaepithelial inflammatory reaction after which hyalinization of the lamina propria takes place. The fibrosis of the muscle causes stiffness of the oral mucosa with increasing difficulty in mouth opening and tongue protrusion resulting in impairment of functions like eating, swallowing, and phonation.  The atrophic epithelium shows first an intercellular edema and later epithelial atypia associated with moderate epithelial hyperplasia. After this, the development of carcinoma may start any time.  It has been proposed that patients suffering from OSMF are at an increased risk of developing oral cancer. The malignant transformation rate of OSMF has been reported to be around 7.6%. 
Although a number of factors have been worked upon, no single pathophysiology has been agreed on and, hence, no effective treatment has come to light. Thus, the management of OSMF poses a great challenge.  One new treatment modality which is gaining recognition is the use of turmeric in OSMF. A number of studies are being conducted all over the world to seek the potential of turmeric and its active component, curcumin, as a chemopreventive agent. The anti-inflammatory and antioxidant properties of curcumin are responsible for its chemopreventive action.  The anti-inflammatory and antioxidant activities of curcumin have been observed in in vitro studies that showed the inhibition of lipo-oxygenase and cyclo-oxygenase (COX) activities that can induce inflammation.  It has been seen that curcumin lowers the activity of STE (smokeless tobacco extract)- or NNK (nicotine derived nitrosamine ketone)-induced NF-κB (nuclear factor kappa-light-chain-enhancer of activated B cells) and COX-2 in oral premalignant and cancer cells.  Turmeric acts by increasing the number of micronuclei in the circulating lymphocytes and by acting as an excellent scavenger of free radicals.  Keeping in mind the studies that have been conducted so far and the therapeutic effects of turmeric, we conducted a study with the aim of evaluating the efficacy of turmeric in patients with OSMF.
| Materials and Methods|| |
This study was conducted in the Department of Oral Medicine and Radiology after obtaining clearance from the institutional ethical committee. Thirty patients who were clinically diagnosed with OSMF were selected for this study. Subjects within the age group of 18-50 years were selected for this study and informed consent was obtained from all the subjects. All the patients gave a positive habit history. Complete hemogram of the subjects was done to rule out any other pathophysiology.
Patients who showed malignant changes or who were not willing for treatment were excluded. For the study, the patient's mouth opening was measured using a digital vernier caliper [Figure 1] and the burning sensation was recorded on the Visual Analog Scale (VAS). Using the interincisal distance, the patients were divided into four different groups based on Lai's (1995)  staging of OSMF as follows:
|Figure 1: Image showing measurement of mouth opening using digital vernier caliper|
Click here to view
- Group A: >35 mm
- Group B: Between 30 and 35 mm
- Group C: Between 20 and 30 mm
- Group D: <20 mm
Each patient was given the commercially available turmeric, Turmix (Sanat Products Ltd., Bulandsheher, Uttar Pradesh, India) tablet containing curcumin 300 mg and piperine 5 mg. This tablet was given orally thrice daily for 1 month. The responses were assessed clinically on a trimonthly basis. Every time the patient was recalled, the patient's mouth opening and burning sensation on VAS were recorded and compared. Student's t-test was used for statistical analysis.
| Results|| |
Out of the total 30 patients diagnosed with OSMF included in this study, the maximum number of patients was in the age group 21-30 years, accounting for 36.7% of the study group. The mean age of the study group patients was 35.1 ± 11.4 years. The male:female ratio in the study group was 2.3:1. These subjects were then divided into four different groups based to Lai's classification, and the maximum number of patients, i.e. 12 out of 30 patients, belonged to group C stage of OSMF and the least number of patients, i.e. 3 out of 30 patients, belonged to group B. Out of the remaining 15 patients, 7 patients belonged to group A while 8 patients were of group D. Maximum number of erosions was observed in subjects belonging to group B, along the right and left buccal mucosa.
When the groups were individually studied, an improvement of 4.01% (10.4 mm) in mouth opening with an improvement of 82.50% (33) in burning sensation on VAS was noticed in group A. In group B, an improvement of 1.52% (1.4 mm) in mouth opening and 83.33% (5) in burning sensation was seen, while in group C, an improvement of 0.77% (2.3 mm) in mouth opening and 66.10% (39) in burning sensation was noticed. In group D, an improvement of 5.16% (6.5 mm) in mouth opening and 71.67% (43) in burning sensation was seen.
Graph 1 [Additional file 1] and Graph 2 [Additional file 2] show the comparison of improvement in mouth opening and burning sensation (VAS), respectively, among the four groups. From the data obtained, we could conclude that the group which showed maximum improvement in mouth opening was group D and the group that showed least improvement was group C. Regarding burning sensation, group B showed maximum improvement, while group C showed the least improvement.
Graph 3 [Additional file 3] and Graph 4 [Additional file 4] show the comparison of overall improvement in mouth opening and burning sensation (VAS), respectively. When the overall improvement was considered, the change in mouth opening was not statistically significant (P = 0.109), with the improvement in mouth opening being 0.69 cm. The change in burning sensation on VAS was statistically significant (P < 0.001).
| Discussion|| |
In 1952, Schwartz named an oral fibrosing disease that he found in five Indian women from Kenya as atrophica idiopathica mucosa oris. Joshi named the condition as submucous fibrosis (OSMF) in 1953. Submucous fibrosis is an insidious, chronic disease affecting any part of the oral cavity and sometimes the pharynx. Occasionally, it is preceded by and/or associated with vesicle formation and is always associated with a juxtaepithelial inflammatory reaction followed by progressive hyalinization of the lamina propria.  In 1997, Cox and Aziz mentioned that in OSMF, increasing inability to open the mouth is the most common complaint, occurring as a result of accumulation of fibrous tissue in the juxtaepithelial region of the oral mucosa.  In 1956, Paymaster was the first one to describe the precancerous nature of OSMF when he noticed a slow-growing squamous cell carcinoma (SCC) in one-third of the patients diagnosed with the disease. 
The etiology and pathogenesis of the disease is not well known; hence, it is believed that OSMF is caused by many factors. Pindborg, in 1968,  and Caniff et al., in 1986,  described the disease as a reaction to capsaicin, an irritant in chilies, but this was not completely proved in experimental work.  Although a number of factors have been thought to be responsible, yet no effective treatment is available for this disease. 
One new treatment modality which is gaining recognition is the use of turmeric in OSMF. Curcumin is the principal curcuminoid and comprises approximately 2-5% of turmeric.  When the 30 patients were administered turmeric, an improvement in mouth opening and burning sensation was noticed. Group A showed an improvement of 4.01% (10.4 mm) in mouth opening, in comparison to 1.52% (1.4 mm), 0.77% (2.3 mm), and 5.16% (6.5 mm) in groups B, C, and D, respectively. We could hence hypothesize that maximum improvement was seen in group D due to the fact that curcumin has fibrinolytic and anti-inflammatory action and the severity of fibrosis and inflammation was maximum in group D. Curcumin exerts anti-inflammatory activity by inhibiting a number of different molecules that participate in the process of inflammation.  Curcumin also has a fibrinolytic property due to its ability to inhibit lipid peroxidation and check cellular proliferation, thereby reducing the rate of collagen synthesis. 
The other factor that we considered in our study was improvement in burning sensation on VAS. An improvement of 82.50% (33), 83.33% (5), 66.10% (39), and 71.67% (43) was seen in groups A, B, C, and D, respectively. Maximum improvement was seen in group B, which can be due to the fact that group B subjects had the maximum number of erosions present on clinical examination.
When the overall improvement was considered, the change in mouth opening was not statistically significant (P = 0.109); however, the improvement in mouth opening was 0.69 cm which was similar to the result of a study conducted by Das et al. in 2010, where they noticed an improvement of 0.87 cm in mouth opening. Although the improvement in mouth opening was not significant (P = 0.109), we still recorded an improvement of 0.69 cm, which could be due to the fact that this was a short-term study. The change in burning sensation on VAS was statistically significant (P < 0.001), which was similar to the observations by Das et al. 
| Conclusion|| |
Thus, we can conclude that turmeric has a therapeutic effect in patients diagnosed with OSMF. Turmeric is considered a safe, nontoxic, and effective alternative for many conventional drugs due to its distinguished therapeutic properties and multiple effects on various systems of the body. Its role in the treatment of oral cancers is very promising. However, there is not enough information and research in this field, and therefore, further research is required to determine the efficacy of curcumin. As this was a short-term study, further research is needed with a larger sample size over long term to achieve more definite results.
| References|| |
|1.||Dyavanagoudar SN. Oral submucous fibrosis: Review on etiopathogenesis. J Canc Sci Ther 2009;1:72-7. |
|2.||Rajendran R. Oral submucous fibrosis: Etiology, pathogenesis, and future research. Bull World Health Organ 1994;72:985-6. |
|3.||Kumar SP, Shenai P, Chatra L, Rao PK, Veena KM. Oral submucous fibrosis as a forerunner of malignancy: A case report. Biol Biomed Rep 2012;2:119-22. |
|4.||Taneja L, Nagpal A, Vohra P, Arya V. Oral submucous fibrosis: An oral physician approach. J Innov Dent 2011;1:14-18. |
|5.||Lawande SA. Therapeutic applications of turmeric (Curcuma longa) in dentistry: A promising future. J Pharm Biomed Sci 2013;27:586-91. |
|6.||Bar-Sela G, Epelbaum R, Schaffer M. Curcumin as an anti-cancer agent: Review of the gap between basic and clinical applications. Curr Med Chem 2010;17:190-7. |
|7.||Rai B, Kaur J, Jacobs R, Singh J. Possible action mechanism for curcumin in pre-cancerous lesions based on serum and salivary markers of oxidative stress. J Oral Sci 2010;52:251-6. |
|8.||More CB, Gupta S, Joshi J, Varma SN. Classification system for oral submucous fibrosis. J Indian Acad Oral Med Radiol 2012;24:24-9. |
|9.||Aziz SR. Oral submucous fibrosis: An unusual disease. J N J Dent Assoc 1997;68:17-9. |
|10.||Gupta MK, Mhaske S, Ragavendra R, Imtiyaz. Oral submucous fibrosis - Current concepts in etiopathogenesis. People's J Sci Res 2008;1:39-44. |
|11.||Pindborg JJ. Is submucous fibrosis a precancerous condition in the oral cavity? Int Dent J 1972;22:474-80. |
|12.||Caniff JP, Harvey W, Harris M. Oral submucous fibrosis: Its pathogenesis and management. Br Dent J 1986;160:429-34. |
|13.||Sabharwal R, Gupta S, Kapoor K, Puri A, Rajpal K. Oral submucous fibrosis: A review. J Adv Med Dent Sci Res 2013;1:29-37. |
|14.||Akram M, Uddin S, Ahmed A, Usmanghani K, Hannan A, Mohiuddin E, et al. Curcuma longa and curcumin: A review article. Rom J Biol-Plant Biol 2010;55:65-70. |
|15.||Das AD, Balan A, Sreelatha KT. Comparative study of the efficacy of curcumin and turmeric oil as chemopreventive agents in oral submucous fibrosis: A clinical and histopathological evaluation. J Indian Acad Oral Med Radiol 2010;22:88-92. |