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 Table of Contents  
REVIEW ARTICLE
Year : 2022  |  Volume : 34  |  Issue : 1  |  Page : 106-111

Evaluation of ayurvedic treatment modalities for oral lichen planus – A systematic review


Department of Oral Medicine and Radiology, Dr. D. Y. Patil Vidyapeeth, Pune, Maharashtra, India

Date of Submission24-Dec-2020
Date of Decision18-Oct-2021
Date of Acceptance09-Nov-2021
Date of Web Publication25-Mar-2022

Correspondence Address:
Dr. Subhadeep A Gupta
Dr. D. Y. Patil Dental College and Hospital, Sant Tukaram Nagar, Pimpri, Pune, Maharashtra - 411 018
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jiaomr.jiaomr_276_20

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   Abstract 


Oral lichen planus (OLP), a chronic inflammatory disease that affects the oral mucosa, may cause pain or discomfort along with increased burning sensation. There are numerous treatment modalities available that have several side effects. The aim of this study was to determine the effectiveness of Ayurvedic management for oral Lichen Planus. Two sources of Internet were used to search appropriate articles which satisfied the purpose of study including PubMed and Google scholar. Studies which were done on Indian population, PubMed search including articles that were published between January 1, 2000 and October 31, 2019, Studies published in English or which could be translated to English, randomized clinical trials, controlled clinical trials and longitudinal studies with essential data on Ayurvedic approach were included. Patients having Oral Lichen Planus where ayurvedic approach was used for treatment. Out of 09 articles, included in systematic review, in almost all the studies improvement in pain, erythema and burning sensation were reported in score scale. Administration of topical herbal antioxidants and topical application of herbal medicines prove to be effective approach in minimizing the signs and symptoms of Oral Lichen Planus. Long-term use of steroids has many side effects while the herbal medicines almost have none. So, herbal medicines can be used for better efficacy with least side effects for OLP.

Keywords: Aloe vera, oral lichen planus, sesame oil, tulsi


How to cite this article:
Gupta SA, Khare VV, Gaikwad TV, Chavan MS. Evaluation of ayurvedic treatment modalities for oral lichen planus – A systematic review. J Indian Acad Oral Med Radiol 2022;34:106-11

How to cite this URL:
Gupta SA, Khare VV, Gaikwad TV, Chavan MS. Evaluation of ayurvedic treatment modalities for oral lichen planus – A systematic review. J Indian Acad Oral Med Radiol [serial online] 2022 [cited 2022 May 27];34:106-11. Available from: https://www.jiaomr.in/text.asp?2022/34/1/106/340756




   Introduction Top


Oral Lichen Planus (OLP) is a chronic inflammatory disease affecting the oral mucosa presents alone or in combination with skin lesions it has varoius types of presentation which include reticular, papular, plaque like, erosive, atrophic or bullous. The buccal mucosa, tongue and gingiva are most commonly involved sites intraorally.[1] The etiology and pathogenesis of OLP is vast. It has been said to be associated with multiple disease processes and agents including viral and bacterial, autoimmune diseases, medications, vaccinations and dental filling materials.[2] There is no one recommended therapy for OLP but Steroids remain the mainstay. Alternative treatment options include retinoids, UV phototherapy, steroid-sparing agents and pimecrolimus.[3]

No treatment resolves the lesions completely. The management revolves around use of drugs that decrease inflammation of the tissues and various mechanisms of immunology. There is lot of inconvenience in using all these treatment modalities because of the side effects they generally produce.[4] Resistance to treatment, recurrence of lesion and an increased risk of toxicity limit the use of all the mentioned drugs. The prolonged use of topical and systemic steroids may result in atrophy of mucosa, secondary candidiasis and systemic toxicity with recurrent relapses and remissions. Therefore, herbal medicines can be a suitable alternative to other routinely used synthetic drugs.[3]

As a clinician, it is very important to prescribe those medications which have sufficient significant evidence in the literature. Systematic review shows an evidence-based information to come to a conclusion. A total of 09 studies were included under this review according to the mentioned eligibility criteria which have been discussed in terms of treatment modalities, sample size, duration of study, reduction in signs and symptoms.


   Objectives Top


To determine the effectiveness of Ayurvedic management for oral lichen Planus.


   Methods Top


Eligibility criteria

Inclusion criteria

  1. Studies done on Indian population to assess the effectiveness of Ayurvedic approach in OLP patients
  2. PubMed search including articles published from January 1st, 2000 to October 31st, 2019
  3. Studies that were published in English or which could be translated into English
  4. Randomized clinical trials, controlled clinical trials and longitudinal studies with essential data on Ayurvedic approach
  5. Studies including all six Clinical types of OLP.


Exclusion criteria

  1. All sort of Reviews, case reports, editorials, abstracts, letters and short communications.


Information sources

For the searching of appropriate papers satisfying the study purpose, two Internet sources of evidence were used. One was PubMed and the other one was Google scholar. For additional papers that could meet the eligibility criteria of the study, all cross-references of the selected articles were also screened. The databases were searched from January 1st, 2001 till October 31st, 2019 using the search strategy.

Search

Keywords shown in [Table 1].
Table 1: Keywords used for the search

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Study selection

Preliminary screening resulted in a total of 210 articles. Screening was done of the titles of these 210 articles. After going through them, 90 articles were selected as the remaining didn't fit into the search criteria. Then the second step was removal of the duplicate articles from the selected articles. 50 articles were found to be duplicates which were removed and that resulted in a number of 40 articles. These 40 articles were screened based on the content of their abstract. From these, 20 articles were excluded as they did not fit our eligibility criteria. Out of the remaining 20 articles 11 were rejected being the reason; two articles were review studies, three were not available in English language, three articles were not available online as they were not yet published, two were short communication and one article provided data according to age distribution. Finally, 09 articles were included in systematic review. [Table 2] shows the selected articles based on the search strategy. And [Figure 1] shows the PRISMA chart for the article selection.
Table 2: Search strategy and articles selected

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Figure 1: Prisma diagram

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Data collection process

An excel spreadsheet with relevant headings as per the review was prepared. This pilot sheet was reviewed by an expert and the changes were made accordingly into it. Now, all the relevant information according to the headings was extracted from the included 9 articles. Initially, data extraction of only one study was done which was approved by an expert. Later data for remaining studies was extracted. [Table 3] shows the data extraction sheet of the data collected from the 9 papers.
Table 3: Data extraction from 9 papers

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Data items

The data items included:

  1. Study Id
  2. Author
  3. Year of publication
  4. Study design
  5. Intervention group – Treatment given
  6. Sample size
  7. Duration of the study
  8. Pain, Erythema & Burning sensation at baseline and at the end of the treatment procedure in the intervention group.
  9. Outcome (intervention) – Study result in the intervention group, decrease in pain Erythema, burning sensation in %.
  10. Outcome (control) – Study result in the intervention group, decrease in pain, erythema, burning sensation in %
  11. Conclusion- Interpretation of the findings
  12. Remarks – Comments given by the author.



   Results Top


A total of 09 studies were a part of this systematic review according to the eligibility criteria. Though the inclusion criteria for year of publication was from the year 2000 to 2019 but still most of the studies were found post 2009. Almost all the studies included were randomized clinical trials except one by Vibha Singh et al.[5] which was a pilot study.

All the studies included patients either by confirming OLP through clinical diagnosis or by histopathological findings.[4],[5],[6],[7],[8],[9],[10],[11],[12] The patients were instructed to change their lifestyle in all the studies. In studies by N. Chainani-Wu et al.[6] and Keshari et al.,[11] curcumin was used as the treatment modality. Aloe vera was used in 3 studies by N. Salazar-Sánchez et al.,[4] Mansourian et al.[8] and Reddy et al.[9] In a study by Inamdar et al.,[10] Aloe-Vera, Licorice and sesame oil was used in a single formulation. In a study by Bacci et al.,[7] topical tocopherol was used as the treatment modality while in study by Sawarn et al.,[12] lycopene tablets were used. Almost all the studies were effective in decreasing the signs and symptoms of Oral Lichen Planus with the help of herbal medicines which either had to be applied topically over the affected site or were in the form of lozenge or tablets.

Most of the studies included in this review had a small sample size ranging from 30 patients to 50 patients. One of the studies by Singh et al.[5] had only 10 patients in each group. While a comparatively larger sample size of 40-50 patients was observed in studies by N. Chainani-Wu et al.[6] and Bacci et al.[7] Lesser the sample size more it is difficult to rely on the results. The difference observed in the results may also be accounted to the variation in sample size. In almost all the studies improvement in pain, erythema & burning sensation was reported in score scale [Table 3]. No side effects were observed in any of the studies except for the study by Singh et al.,[5] where mild irritation at the application site was noted.


   Discussion Top


Lichen planus which is mediated by T-cell is an autoimmune condition that affects the skin and the oral mucosa. Oral Lichen Planus which is the mucosal counterpart of cutaneous lichen planus which shows a female predominance and is seen most commonly in the fourth decade of life.[13] It affects 0.5–2.0% of the population.[14] It shows mild to moderate white keratotic lesions which are painless on the oral mucosa. Sometimes it shows painful ulcerations and erosions. It can be classified into atrophic, reticular, erosive and bullous type.[15] The most common site of occurrence is the posterior part of buccal mucosa, which is followed by the anterior two third of tongue, labial mucosa, attached gingiva and vermilion of the lower lip.[16]

The autoimmune disease, OLP is mediated by T-cells. The auto-cytotoxic CD8+ T cells are responsible for triggering apoptosis of the basal cell layer of the epithelium of oral cavity. There are various antigen-specific and non-specific inflammation mechanisms which explain the CD8+ T cells accumulation sub-epithelially and the subsequent apoptosis of keratinocytes.[1] Many treatment modalities are present with the goal of improving the lesions and reduction of the pain associated. But corticosteroids are the most commonly used drugs for management and treatment of OLP. There are few other drugs which have also shown good results in the treatment of OLP. They include, hydroxychloroquine, calcineurin inhibitors, dapsone, retinoids, mycophenolatemofetil and enoxaparin. There are various side effects of corticosteroid therapy which include, hypertension, adrenal suppression, etc., which may present due to prolonged use. Therefore, natural or herbal drugs with antioxidant or anti-inflammatory effects, individually or in combination with corticosteroids, have been considered for the effective treatment and management of OLP.[13] Treatment with corticosteroids is usually symptomatic and doesn't lead to complete cure of the disease due to which the recurrence of lesion occurs, and the patients are required to use medications for a prolonged period of time. Also, drugs with immunosuppressive action such as cyclosporine and tacrolimus have wide range of side-effects. The most common adverse effects of corticosteroid therapy include, local irritation, tingling, burning, fungal infection, taste disturbances and nausea.[8]

Ayurveda, the traditional system of natural medicine in India is one of the emerging treatment modalities worldwide, for the treatment and prevention of various diseases. For the treatment of various health problems, ayurvedic gels, mouth washes etc., are being used since a long duration of time. In today's world where steroids and other drugs with wide range of adverse effects, are being commonly used for treating various oral diseases, scientists are still searching for other modalities with equal potency and least side-effects.[17] Some antioxidants like β carotene, provitamin A, vitamin-E, vitamin-C, selenium, zinc and spirulina are known to prevent various diseases.[18] Ayurvedic medicines also hold good result in this aspect. Ayurvedic treatment of any disease involves a comprehensive treatment strategy which involves strengthening of the digestive system, detoxification of the body and rejuvenation. This involves dietary modification, Panchakarma therapy, controlling and reducing the symptoms with herbal medicines.[19]

Aloe vera (AV) is a member of the Liliacea family. It is widely used for natural therapy and alternative treatment for various diseases. A huge number of studies have shown the healing, nutritional and cosmetic advantages of this miraculous plant.[20],[21] AV can reduce burning in lichen planus by inhibiting the inflammatory process by its interfering action on the arachidonic acid pathway via cyclooxygenase and also by the reduction of leucocyte adhesion and TNF-a level.[22] AV is also used to treat lichen planus in many studies including the ones which have been included in this review.[4],[8],[9],[10] Aloe Vera when used as a formulation with sesame oil and licorice has shown 95.5% effectiveness in reducing the burning sensation. Sesame oil is mentioned in the Vedas as excellent for humans and is a natural anti-inflammatory agent.[10] On the other hand, when aloe-vera was used individually in studies by Mansourian et al.,[8] Salazar-Sánchez et al.[4] and Reddy et al.,[9] it has shown to reduce burning sensation by 87.9%, 89.5% and 90% respectively. Also, in another study by Muthusamy and Dharman.,[16] it was concluded that aloe vera is useful in decreasing pain and improving the clinical signs and symptoms of Oral lichen Planus when compared to placebo.

Curcumin, a constituent of turmeric has been used widely in Ayurvedic medicine for years because of its therapeutic and non-toxic properties which includes antioxidant, analgesic, anti-inflammatory, antiseptic effects, and anticarcinogenic behavior. Curcumin has also shown to have immune-modulatory effect involving activation of host macrophages and natural killer cells and modulation of lymphocytes mediated function.[5] These characteristics have led to the need for checking its efficacy on oral conditions like lichen planus.[11] In the studies by Keshari et al.,[11] Singh et al.[5] and Chainani-Wu et al.,[6] Curcumin has shown to reduce the burning sensation by 92%, 95.5% and 90% respectively. In a case report by Prasad et al.,[15] Curcumin has shown excellent results in improvement of symptoms of recurrent oral lichen planus.

Tocopherol is an essential vitamin for human nutrition. It is a powerful antioxidant which is liposoluble. Vitamin E has a fundamental job as an antioxidant in preventing oxidation of polyunsaturated fatty acids, an important event in the procedure of peroxidation of lipid. The peroxidation of lipids can show profound changes in the membranes of the cells; therefore, vitamin E is acknowledged as having a key role in maintaining the intactness of these structures.[7] Therefore, it has been used to treat OLP in a study by Bacci et al.[7] It shows an efficacy of 86.7% in reducing burning caused due to Oral Lichen Planus.

Lycopene, a red-colored, fat-soluble carotenoid is responsible to impart deep red color to tomatoes and other fruits. The numerous advantages of this compound on health of humans can be explained based on its properties of antioxidation, inhibition of proliferation of cancer cells, interference with stimulation of growth factor, phase II enzymes induction, regulation of transcription and restoring of gap junctions.[12] In a study by Saawarn et al.,[12] it shows improvement in burning sensation by 97%.

Treatment for OLP still remains a challenge. The commonest treatment modalities used till date are Topical & Systemic Steroid. In the topical category administration of steroid injections, antioxidants are usually provided. But they have their own side effects and thus ayurvedic medicines can be used as a safe alternative that has been discovered in the literature.

Limitations

  • Only two data base i.e., PubMed and Google scholar were used for searching articles
  • Only free text articles were selected
  • Only articles published in English language were considered.



   Conclusions Top


We can conclude that, administration of topical herbal antioxidants and topical application of herbal medicines such as Aloe vera, herbal antioxidants curcumin, turmeric, Licorice green tea and sesame oil all prove to be effective in minimizing the signs and symptoms shown in OLP patients. It has now been proved that the herbal way can always be a better option in treating OLP so as to limit the use of Topical & Systemic steroid which have their own side effects such as hypertension, diabetes, gaining of weight, elevated vulnerability to infection, osteoporosis, cataracts, skin thinning, bruising easily, and weakness of muscles.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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Lavanya N, Jayanthi P, Rao UK, Ranganathan K. Oral lichen planus: An update on pathogenesis and treatment. J Oral Maxillofac Pathol 2011;15:127-32.  Back to cited text no. 1
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Boorghani M, Gholizadeh N, Taghavi Zenouz A, Vatankhah M, Mehdipour M. Oral lichen planus: Clinical features, etiology, treatment and management; a review of literature. J Dent Res Dent Clin DentProspects 2010;4:3-9.  Back to cited text no. 2
    
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Salazar-Sánchez N, López-Jornet P, Camacho-Alonso F, Sánchez-Siles M. Efficacy of topical Aloe vera in patients with oral lichen planus: A randomized double-blind study. J Oral Pathol Med 2010;39:735-40.  Back to cited text no. 4
    
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Singh V, Pal M, Gupta S, Tiwari SK, Malkunje L, Das S. Turmeric-A new treatment option for lichen planus: A pilot study. Natl J Maxillofac Surg 2013;4:198-201.  Back to cited text no. 5
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Chainani-Wu N, Collins K, Silverman S Jr. Use of curcuminoids in a cohort of patients with oral lichen planus, an autoimmune disease. Phytomedicine 2012;19:418-23.  Back to cited text no. 6
    
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Bacci C, Vanzo V, Frigo A, Stellini E, Sbricoli L, Valente M. Topical tocopherol for treatment of reticular oral lichen planus: A randomized, double-blind, crossover study. Oral Dis 2017;23:62-8.  Back to cited text no. 7
    
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Mansourian A, Momen-Heravi F, Saheb-Jamee M, Esfehani M, Khalilzadeh O, Momen-Beitollahi J. Comparison of aloe vera mouthwash with triamcinolone acetonide 0.1% on oral lichen planus: A randomized double-blinded clinical trial. Am J Med Sci 2011;342:447-51.  Back to cited text no. 8
    
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    Tables

  [Table 1], [Table 2], [Table 3]



 

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