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Table of Contents   
ORIGINAL RESEARCH  
Year : 2022  |  Volume : 33  |  Issue : 2  |  Page : 146-151
Efficacy of topical tulsi (Ocimum sanctum) paste for the management of oral submucous fibrosis – A clinical study


1 Department of Oral Medicine and Radiology, KAHER's KLE Vishwanath Katti Institute of Dental Sciences, Belagavi, Karnataka; Department of Oral Radiology, Diya Dental Imaging Centre, Bhopal, Madhya Pradesh, India
2 Department of Oral Medicine and Radiology, KAHER's KLE Vishwanath Katti Institute of Dental Sciences, Belagavi, Karnataka, India
3 Department of Oral Medicine, Radiology and Special Care Dentistry, Saveetha Dental College and Hospitals (Saveetha Institute of Medical and Technical Sciences - SIMATS), Tamil Nadu, India

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Date of Submission24-Sep-2020
Date of Decision11-Jul-2022
Date of Acceptance18-Aug-2022
Date of Web Publication13-Oct-2022
 

   Abstract 


Context: Oral submucous fibrosis (OSMF) is a chronic insidious oral potentially malignant disorder characterized by increased collagen deposition and reduced collagen degradation causing burning sensation and difficulty in mouth opening. Aim: To assess the efficacy of topical Tulsi (Ocimum sanctum) paste for the management of OSMF. Settings and Design: Institution-based clinical trial. Materials and Methods: The study included a total of 60 OSMF patients categorized into three Groups A, B and C (20 in each) depending on the severity according to Lai DR et al. classification. The patients were advised for topical Tulsi paste application and were evaluated for the reduction in the burning sensation and improvement in mouth opening every month for 3 subsequent months using the numeric pain rating scale (NRS) and a Vernier calliper, respectively. Statistical Analysis: The baseline and 3-month recordings were subjected to inter- and intra-group statistical analysis using Kruskal–Wallis analysis of variance (ANOVA), Mann–Whitney U, one-way ANOVA, Tukey's multiple post-hoc and Wilcoxon matched-pairs tests. Results: There was a reduction in the burning sensation and improvement in the mouth opening in all three groups. The reduction in the burning sensation was statistically significant among all the groups (P < 0.05) and the NRS scores after 3 months among the three groups were not statistically significant (P > 0.05). There was a statistically significant difference (P < 0.05) in the improvement of mouth opening between Group A and B; A and C; but not between B and C. Conclusion: Tulsi paste showed a significant reduction in the burning sensation and improvement of the mouth opening thereby proving to be a safe and promising medicament for OSMF.

Keywords: Burning sensation, mouth opening, Ocimum sanctum, oral submucous fibrosis, Tulsi

How to cite this article:
Biswas D, Naik Z, Kumar S L, Patil N, Bagewadi A. Efficacy of topical tulsi (Ocimum sanctum) paste for the management of oral submucous fibrosis – A clinical study. Indian J Dent Res 2022;33:146-51

How to cite this URL:
Biswas D, Naik Z, Kumar S L, Patil N, Bagewadi A. Efficacy of topical tulsi (Ocimum sanctum) paste for the management of oral submucous fibrosis – A clinical study. Indian J Dent Res [serial online] 2022 [cited 2022 Nov 29];33:146-51. Available from: https://www.ijdr.in/text.asp?2022/33/2/146/358457



   Introduction Top


Oral submucous fibrosis (OSMF) is a chronic, potentially malignant disorder of the oral cavity characterized by inflammation, progressive fibrosis of connective tissue and lamina propria involving the oral mucosa, the oropharynx and the larynx.[1] The disease is characterized by blanching and stiffness of oral mucosa, trismus, burning sensation, restricted tongue movement and loss of gustatory sensation. The majority of the cases are reported in the Indian population where the prevalence differs from 0.20% to 0.5%.[2]

Literature reveals areca-nut as the main etiological factor in OSMF, although other factors like hypersensitivity, chillies, genetic predisposition, malnutrition, deficiency of iron, zinc and essential vitamins are attributed. Studies have shown that the alkaloids and flavonoids of areca nut like arecoline, arecaidine, guvacine and guvacoline are the principal etiologic factors with arecoline being the most potent.[3] The etiopathogenesis involves the proliferation of the fibroblasts and increased formation of collagen which is related to the connective tissue growth factor (CTGF). Arecoline stimulates CTGF through the pathways of reactive oxygen species (ROS), NF-kappa B, JNK and p38 MAPK pathways.[4]

The chief complaints of the majority of the patients are burning sensation, due to blister formation/ulceration and difficulty in mouth opening.[5] Clinically, there are palpable bands in the buccal mucosa, around the mouth, and in the soft palate associated with blanching of overlying mucosa.[6] There may be fibrosis of the nasopharynx and difficulty in hearing due to the fibrosis of the  Eustachian tube More Details in advanced stages. Though not definite, there are various treatment modalities like corticosteroid injections, turmeric, lycopene, hyaluronidase, pentoxifylline, levamisole, immune milk, ultrasound, diathermy, chylomicrons, aqueous extracts of healthy human placenta and surgical excision of fibrous bands by surgery for OSMF. However, corticosteroids remain the most promising therapeutic modality.

Literature reveals that even the topical corticosteroids get absorbed systemically and leads to side effects.[7] Various studies have concluded that herbal medicines are naturally effective with fewer side effects and low-cost availability.[2]

Tulsi (Ocimum sanctum) is a holy plant popularly known as the 'Queen of herbs' with a wide range of medicinal properties like antioxidant, anti-inflammatory, analgesic, immunomodulator, antiulcer, anticancer, antipyretic, antidiabetic and anticoagulant property. The chemical constituents present in Tulsi are eugenol, methyl chavicol, linalool, saponins, tannins, ascorbic acid and carotene.[8] It is also known to inhibit acute and chronic inflammation, by blocking the cyclooxygenase and lipoxygenase pathways, as well as the chemical mediators.[9] Hence, it was proposed to study the efficacy of Tulsi extract in the form of topical paste for OSMF.

Objectives of the study

To assess and compare the efficacy of topical Tulsi paste in the reduction of burning sensation and improvement in mouth opening among the patients with Groups A, B and C OSMF (Lai DR classification).[10]


   Materials and Methods Top


Preparation of the Tulsi paste

The topical Tulsi paste was prepared in small quantities (750 g), once in every 3 months, at the constituent College of Pharmacy after obtaining Tulsi leaves from the herbal garden of constituent Ayurvedic College with prior authentication by the Indian Council of Medical Research (ICMR). The leaves were dried under the shade until they became crispy on touching. They were then crushed and converted into a fine powder by passing through 80 meshes.

Sodium carboxymethyl cellulose was weighed and dissolved in 80 ml of water. The solution was stirred for 1 hour and kept for 24 hours soaking. In 20 ml of water, sodium methylparaben, sodium propylparaben and sodium benzoate were weighed, then mixed and dissolved. Sodium carboxymethyl cellulose gel was added to the above solution and it was stirred well to convert into a paste form. Further, Tulsi leaf powder was added slowly with constant stirring. Then glycerine was added and mixed well. Vanillin and xylitol were added to enhance the paste acceptability. The paste was then homogenized using a homogenizer for 15 minutes and stored in airtight sterile plastic containers at room temperature [Figure 1]a. The homogeneity and stability of the preparation was checked by visual/organoleptic examination of the colour, texture, odour and consistency by a single pharmacist once a month for 3 months duration.
Figure 1: (a) Prepared Tulsi paste, (b) baseline and (c) 3 months post-Tulsi therapy mouth opening measurements

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Finally, the composition per 100 g of paste contained 25 g of Tulsi leaf powder-main ingredient, 5 g of glycerine-moistening agent, 0.05 g of sodium benzoate-antifungal agent, 0.05 g of sodium methylparaben-antibacterial agent, 0.05 g of sodium propylparaben-antibacterial agent, 2 g of sodium carboxymethylcellulose-base paste, xylitol-sweetening agent, 0.010 g of vanillin flavour and water.

Methodology

A total of 60 patients reporting to the Department of Oral Medicine and Radiology with the age of 18 years and above, of either sex, were included in the study after clinical confirmation of OSMF and with prior informed consent. However, Group D OSMF patients (Lai DR et al.,)[10] pregnant patients, lactating mothers, patients undergoing some form of OSMF treatment, and patients with systemic diseases were excluded. The study was approved by the Institutional Research and Ethics Committee (Ref. no: 09/06/2016/1071). All the procedures were done in accordance with the ethical standards of the responsible committee on human experimentation and with the Helsinki Declaration of 1964 and later versions. The sample size (n) was estimated to be 17.3 per group with 10% attrition using the formula n = (Z1-α/2 + Z1-β)2 + (SD12 + SD22)/ (12)2, where z = 1.96, α = 5%, 1-β = 95%, SD1 = 5.43, SD2 = 2.60, 1 = 3.02, and 2 = 0.76 in G* Power statistical software (version 3.1.9.2).

Patients were categorized into three groups: A, B and C according to Lai DR et al.,[10] classification-1995, based on the mouth opening. Each of the three groups had 20 patients. A thorough case history was recorded and the patients were counselled to quit the habit of tobacco/pan/areca nut chewing strictly. The patients were also subjected to scaling along with oral hygiene instructions and advised for mouth opening exercises thrice a day for 2 months. During the first visit, baseline measures for the mouth opening and burning sensation were recorded using a Vernier calliper [Figure 1]b and [Figure 1]c and numeric pain rating scale (NRS), respectively. The NRS scores ranged from 0 (no burning sensation) to 10 (extreme burning sensation).

Mouth opening was recorded by measuring the maximum inter-incisal distance from the mesioincisal edge of the maxillary central incisor to that of the mandibular central incisor.

Each patient was dispensed with 60 g of Tulsi paste in a sterile airtight container during every visit. Patients were demonstrated and instructed to apply the paste intraorally using sterile earbuds after drying the oral mucosa with cotton, twice daily in the morning and the night after food. On each application, 250 mg of Tulsi extract in Tulsi paste (1 g) was delivered. The patients were asked not to drink or eat for the next 15 minutes post-application. The therapy was instituted for 1 month and patients were followed up for another 2 months. The patient compliance for topical Tulsi paste therapy was ensured by checking the used empty container brought during the follow-up. In case of any untoward reaction to the medication or any discomfort, the patients were asked to report immediately.

Statistical analysis

The tabulated pre- and post-treatment values were subjected to statistical analysis using SPSS® 17 software package. Statistical tests of age distribution analysis, Kruskal–Wallis ANOVA test, Mann–Whitney U-test, Wilcoxon matched-pairs test and one-way ANOVA test were done.


   Results Top


On age distribution analysis, the maximum number of subjects in Group A were in the age group of 30–49 years (35%). Similarly, the maximum number of subjects in Group B were in the age group 30–39 years (45%) and in Group C were 20–29 years (70%). Overall maximum number of subjects was in the age group of 20–29 years (38%). All the subjects included were males except for two females in Group A who had the habit of chewing betel nut/pan, tobacco or gutkha. The duration and frequency of the habit ranged from 1.5 to 35 years and 3 to 8 times/day, respectively.

NRS score comparison at baseline and after 3 months post-treatment using the Kruskal–Wallis ANOVA test showed that the mean difference among Groups A, B and C was statistically significant with P = 0.0001.

Inter-group comparison of Groups (A, B and C) for NRS scores at baseline and after 3 months by Mann–Whitney U-test presented that the difference among Groups A, B and C was statistically significant (P < 0.05). The difference of NRS scores after 3 months among Groups A, B and C was not significant (P > 0.05) [Table 1].
Table 1: Pair-wise comparison of Groups (A, B and C) with respect to NRS scores at baseline and after 3 months

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Intra-group comparison of the NRS scores at baseline and after 3 months (post-treatment) using the Wilcoxon matched-pairs test in each Group A, B and C was significant (P = 0.0001 < 0.05) [Figure 2]a.
Figure 2: Intra-group comparisons of (a) burning sensation (NRS) scores and (b) mouth opening scores (in millimetres) in three study Groups (A, B and C) at baseline and after 3 months

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Mouth opening comparison among Groups A, B and C at baseline and after 3 months (post-treatment) using one-way ANOVA test depicted significant results at baseline and post-treatment (P < 0.05) [Table 2].
Table 2: Comparison of study Groups (A, B and C) with respect to mouth opening scores at baseline and after 3 months

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Inter-group comparisons of Groups A, B and C to mouth opening at baseline and after 3 months by Tukey's multiple post-hoc test showed that the difference in the mouth opening was significant between Groups A and B, A and C but not significant between B and C (P > 0.05) [Table 3].
Table 3: Pair-wise comparisons of study Groups (A, B and C) with respect to mouth opening scores at baseline and after 3 months

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Intra-group comparison of Groups A, B and C at baseline and post-treatment with respect to mouth opening scores by Wilcoxon matched-pairs test [Group A (P = 0.0002), Group B (P = 0.0028) and Group C (P = 0.0001)] showed a significant increase in mouth opening [Figure 2]b.

The prepared topical Tulsi paste showed a good stability during the visual/organoleptic evaluation. All the involved subjects quit the habit completely which was ensured by the clinical examination for stains and deposits on the teeth during follow-up.


   Discussion Top


Literature reveals various treatment modalities for the management of OSMF.[9] Tulsi extract is a promising medicament possessing anti-inflammatory, analgesic, anti-oxidant and immunomodulatory properties. It is an effective medicament with low toxicity, low cost and high availability.[11] Natural therapies can provide safer and long-term treatment in reducing the symptoms of the disease without any notable side effects.

In the current study, the mean age in Groups A, B and C was 40.60 ± 10.65, 32.70 ± 8.01 and 28.40 ± 7.16, respectively. The maximum number of patients was in the age group 20–29 years and the least number of subjects were above 50 years which was in accordance with Gupta et al.[12] who reported the mean age to be 31.93 years. A similar age group was observed in the study by Shwetha et al.[13] who reported the maximum subjects aged between 21 and 30 years. However, Nigam et al.[14] reported the maximum number of patients in age of 36–40 years which was in contrast to our study, possibly due to our smaller sample size and the changing trends of gutkha chewing habits prevailing more in the younger age group.

The mean burning sensation after the treatment in Groups A, B and C was 2.75, 2.60 and 2.75, respectively (P < 0.05). This was similar to the study by Srivastava et al.,[2] where an overall reduction in the burning sensation after the treatment was 2.22 ± 1.413.

Similar results were observed by Virani D et al.,[15] Rizvi D et al.,[16] Khabiya P et al.[17] and Madhulatha G et al.[18] who reported a reduction in the burning sensation. The previously mentioned studies excluded the OSMF patients who is already under treatment or with other ailments, but did not consider the exclusion of Lai DR et al.,[10] Group D OSMF patients, who require surgical management, as followed in this study. Also, the studies used the application of Tulsi powder in combination with turmeric powder or triamcinolone/antioxidants along with glycerine, or Tulsi gel, 2 or 4–5 times a day, for a duration ranging from 1.5 to 3 months. However, the aforementioned studies had no segregation in terms of severity, except for Virani D et al.[15] There was no significant difference in burning sensation among the intergroup comparisons of Groups A, B and C after the follow-up which was in accordance with Rizvi D et al.[16] However, this result was not in accordance with Agarwal et al.[19] who observed significant burning reduction among Groups A, B, C and D (Lai DR classification). Tulsi has potent analgesic, anti-inflammatory and negligible anaesthetic properties justifying the lack of observing a significant difference among the three groups. Also, the burning sensation is a subjective entity which vary for different subjects.

The current study showed statistically significant improvement of mouth opening in Groups A (P = 0.0002), B (P = 0.0028) and C (P = 0.0001) which is in accordance to Srivastava et al.,[2] Virani D et al.,[15] Rizvi D et al.,[16] Khabiya P et al.,[17] and Madhulatha G et al.[18] When intergroup comparisons were done, the pre- and post-treatment difference in the mouth opening between Group A and B was significant. The pre- and post-treatment difference between Groups A and C was also significant but Group B and C revealed no difference in improvement in the mouth opening. As OSMF progresses, there is a gradual increase in the fibrosis of the oral mucosa. Tulsi lacks fibro-lytic action which could substantiate for lack of improvement in mouth opening. Reduced mouth opening and inaccessibility to posterior buccal mucosa in patients with OSMF might lead to difficulty in applying the Tulsi paste effectively.

Tulsi has potent analgesic and anti-inflammatory properties. According to literature, eugenol is the major constituent in Tulsi extracts. The volatile oil contains about 71% eugenol and 20% methyl eugenol. The potent analgesic effect of Tulsi is due to the inhibition of COX-2 inflammatory mediators.[20] These actions are due to the presence of fixed oils and linolenic acid present in Tulsi leaves. Thus, a reduction in burning sensation in OSMF patients is due to the potent analgesic and anti-inflammatory properties of Tulsi.

Local continuous irritation by gutkha, pan masala and areca nut leads to cytokine production and oxidative stress following which there is increased production of ROS that plays an important role in pathogenesis causing cell apoptosis and induce cell proliferation. Tulsi was the choice due to its potent anti-oxidant and immunomodulatory activities. It contains urosolic acid which suppresses various carcinogens and inhibits the proliferation of the cells.[21] Many herbal antioxidants such as lycopene, turmeric, aloe vera have been used for the management of OSMF as adjuvant therapy or along with intralesional injections.[11] Burning sensation and erosions are the initial symptoms and signs reported in early cases of OSMF. This affirms the use of Tulsi paste as a potent anti-inflammatory, analgesic, immuno-modulatory and non-invasive modality for the management of the early stages of OSMF. Almost all the patients responded to Tulsi paste and there were no dropouts, side effects or any signs of toxicity.


   Limitations Top


The limitations of the study were smaller sample size, short patient follow-up and lack of control group receiving the standard treatment of corticosteroids.


   Conclusion Top


The study concluded that Tulsi paste showed a significant increase in the mouth opening as well as a reduction in the burning sensation in all the three groups of OSMF attributing to the analgesic, anti-inflammatory and immunomodulatory properties of Tulsi paste thus making it a very safe and promising cost-effective medication for the treatment of OSMF. Thus, Tulsi paste can be used as a primary mode of treatment in Group A patients with OSMF and as adjuvant therapy for other groups of OSMF in the future.

Acknowledgements

We would like to acknowledge the support of Dr. Shivalingappa B Javali, Associate Professor of Biostatistics, KAHER for statistical analysis and Dr. U B Bolmal, Retd. Assistant Professor of Pharmaceutics, KLE College of Pharmacy for the preparation of Tulsi paste.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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Correspondence Address:
Dr. S Lokesh Kumar
Senior Lecturer, Department of Oral Medicine, Radiology and Special Care Dentistry, Saveetha Dental College and Hospitals (Saveetha Institute of Medical and Technical Sciences - SIMATS), 162, Poonamalle High Road, Chennai - 600 077, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijdr.IJDR_929_20

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