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Table of Contents   
ORIGINAL RESEARCH  
Year : 2013  |  Volume : 24  |  Issue : 3  |  Page : 347-350
Efficacy of spirulina as an antioxidant adjuvant to corticosteroid injection in management of oral submucous fibrosis


Department of Oral Medicine and Radiology, Yenepoya Dental College, Yenepoya University, Mangalore, Karnataka, India

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Date of Submission20-Aug-2011
Date of Decision16-Oct-2012
Date of Acceptance29-Nov-2012
Date of Web Publication12-Sep-2013
 

   Abstract 

Background and Objectives: Oral submucous fibrosis (OSF) is a chronic condition of the oral cavity which results in permanent disability. A number of studies have proven that the management of premalignant diseases should include antioxidants. Therefore, a study was carried out to evaluate the efficacy of spirulina as an antioxidant adjuvant to corticosteroid injections in the management of 40 oral submucous fibrosis subjects of south Karnataka and north Kerala.
Materials and Methods: An intervention study was conducted on 40 oral submucous fibrosis cases, 40 patients were divided into two groups, group A (spirulina group) and group B (placebo group). Group A received spirulina 500 mg twice daily and biweekly intralesional steroid injection of Betamethasone 4 mg/ml for 3 months and group B was given placebo capsules twice daily and biweekly intralesional steroid injection of Betamethasone 4 mg/ml for 3 months. The results were analyzed with the paired " t" test and the unpaired " t" test.
Results: Clinical improvements in mouth opening was significant in the posttreatment period in both Spirulina and placebo groups. Both the groups showed statistically significant reduction in burning sensation. However, when both groups were compared, mouth opening and burning sensation was found to be statistically very highly significant in favor of the spirulina group.
Conclusion: Spirulina can bring about clinical improvements in OSF patients. The observed effects suggest that spirulina can be used as an adjuvant therapy in the initial management of OSF patients. However, studies involving larger samples and longer period of treatment follow up are suggested in the future.

Keywords: Antioxidant, oral submucus fibrosis, spirulina

How to cite this article:
Shetty P, Shenai P, Chatra L, Rao PK. Efficacy of spirulina as an antioxidant adjuvant to corticosteroid injection in management of oral submucous fibrosis. Indian J Dent Res 2013;24:347-50

How to cite this URL:
Shetty P, Shenai P, Chatra L, Rao PK. Efficacy of spirulina as an antioxidant adjuvant to corticosteroid injection in management of oral submucous fibrosis. Indian J Dent Res [serial online] 2013 [cited 2019 May 27];24:347-50. Available from: http://www.ijdr.in/text.asp?2013/24/3/347/118001
Oral submucous fibrosis (OSF) is defined as "an insidious chronic disease" affecting any part of the oral cavity and sometimes the pharynx. Although occasionally preceded by and associated with vesicle formation, it is always associated with a Juxta-epithelial inflammatory reaction followed by a fibro elastic change of the lamina propria with epithelial atrophy leading to stiffness of the oral mucosa and causing trismus and inability to eat. [1] OSF is considered as one of the potentially malignant disorders of the oral mucosa. [2],[3] It is widely regarded that the areca nut alkaloids and tannins play an important role in etiology of OSF. [4] Flavonoid components of areca nut have some direct influence on collagen metabolism. It has been found that exposure of alkaloids to mucosal fibroblasts results in the accumulation of collagen.

Several studies on humans have confirmed the cancer preventive nature of antioxidants. So far, various antioxidant treatment modalities (licopene, ALA, etc) have been tried with varying degree of success. [5],[6]

The Role of spirulina which is an antioxidant has not been well established for the treatment of OSF. Therefore, this study was undertaken to evaluate the efficacy of spirulina as an antioxidant adjuvant to corticosteroid injections in the management of OSF.


   Objective Top


To determine the role of spirulina as an antioxidant adjuvant to corticosteroid injection in management of OSF.


   Materials and Methods Top


A study was conducted on human subjects of our institution, after obtaining the ethical committee approval. The subjects in this study consisted of 40 clinically and histopathologically confirmed OSF patients. Only stage 1 and stage 2 OSF patients were included for the study. Patients with any systemic disorders and on any other medications or therapy were excluded from the study.

In this study, 40 patients were divided into two groups, group A (spirulina) and group B (placebo). Both the groups were counseled for deleterious habits and advised to discontinue the use of areca nut in all preparations before commencing treatment. Both the groups were biweekly treated with steroid injection (Betamethasone 4 mg/ml) by the multiple puncture method. Group A was given antioxidants (Spirulina 500 mg) orally twice daily for 3 months and group B was given placebo capsules daily two times for 3 months. On every visit, patient's mouth opening was assessed by measuring the interincisal distance from the mesioincisal edge of the upper left central incisor tooth to the mesioincisal edge of the lower left central incisor tooth by using a calibrated Vernier caliper and recorded in millimeters. Burning sensation was evaluated by using the Visual Analog Scale (VAS), weekly over a period of 3 months.

The result thus obtained was subjected to statistical analysis. Student's paired and unpaired "t" tests and Chi square test were used for statistical evaluation.


   Results Top


The data collected was statistically analyzed and the results showed the following observations.

Maximum numbers of patients were in the third decade of life with the youngest patient aged 18 years and the oldest patient aged 56 years. The mean age of the individuals in group A was 28.05 yrs, whereas in group B the mean age was 30.75 yrs.

The mean value for initial mouth opening of the spirulina group was 31.05 and that for the placebo group was 32.95; statistically no differences were found.

In group A, an improvement in mouth opening by the end of 2 nd week was observed when compared with that of initial mouth opening value, mean improvement was 1.2000 ± 1.19649. In group B, improvement in the mouth opening by the end of 2 nd week compared with that of initial mouth opening, improvement was. 3500 ± 0.58714. When inter-comparison between two groups was done it was found to be statistically highly significant in favor of group A. These values remained very highly significant even after a 3 month period.

The mean pretreatment mouth opening values in group A was 31.05 mm and the mean value for post treatment mouth opening was 36.8 mm. The mean paired differences were 5.75 mm. The paired difference was statistically highly significant.

The mean pretreatment mouth opening value in group B was 32.95 mm and the mean value for post treatment mouth opening was 35.8 mm.

The mean paired difference was 2.85 mm. The paired difference was statistically significant.

When both the groups were compared, mouth opening values were found to be more in the spirulina group than in the placebo group [Table 1] and [Figure 1].

The mean value of initial VAS of group A was 5.8 and group B was 5.3; statistically no differences were found. There was statistical significance in favor of group A found when values of both groups were compared every 15 days.
Table 1: Compared mouth opening values

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Figure 1: Comparison of mean mouthopening between two groups among different period

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In group A, VAS by the end of 2 nd week compared with that of initial VAS values, the mean difference was 1.00 ± 0.79472. In group B, VAS by the end of 2 nd week compared with that of initial VAS value, the mean difference was. 5500 ± 0.82558. When inter-comparison between two groups was done it was found to be statistically non-significant. VAS in group A at the end of 6 week compared with that of initial VAS mean difference value was 3.200 ± 1.19649. In group B, VAS at the end of 6 week compared with that of initial VAS mean difference value was 1.5500 ± 1.19097. When two groups were compared it was found to be statistically very highly significant in favor of group A and these values remained very highly significant even after 3 months period (post-treatment).

In group A, the mean paired VAS difference was 4.6, and in group B the paired VAS difference was 2.65.

When both the groups were compared, VAS values were less in group A than in group B [Figure 2] and [Table 2].
Table 2: Compared VAS values

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Figure 2: Comparison of mean Visual Analog Scale between two groups among different period

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   Discussion Top


To date OSF is poorly understood and unsatisfactorily treated. Based on clinical, epidemiological, and in vitro studies, areca nut chewing is considered an important predisposing factor. 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, micronutient supplementation, physiotherapy, and surgery. [7]

Spirulina is a microalgae, used in daily diet of natives in Africa and America. It contains phenolic acid, tocopherols, and beta-carotene which are known to exhibit antioxidant properties. [8] Spirulina has been used for the treatment of several oral mucosal lesions with successful results. However, its effects on OSF are not well documented.

Analyzing the results of this study, it can be noted that the average improvement in mouth opening in group A increased by 5.75 mm, but in some individual cases, patient showed maximum mouth opening improvements from 8 to 10 mm. The change in mouth opening was very highly statistically significant and evaluation on a weekly basis showed that the changes maintained were very highly significant from the 2 nd week onward till the end of the treatment.

Group B patients showed an average improvement of 2.85 mm although in some individual cases patients showed maximum mouth opening improvements of 3 to 5 mm. The change in mouth opening was highly significant statistically. When both the groups were compared, mouth opening improvement values were found to be more in group A than in group B.

There is a 50% improvement in mouth opening seen in OSF patients treated with antoxid was reported in a study which was done in 2004. [9] Another study reported an improvement of 17.9% in mouth opening in their OSF patients who were being treated with micronutrient and mineral supplementation. [10]

A report in 1986 stated that the management of OSF purely by means of intralesional steroids has been widely unsatisfactory and it was deemed useful only for patients with minimal impairment of mouth opening. [11] The improvement seen in this study therefore must be attributed to the combination of spirulina with steroids that may exert its action synergistically.

In this study though the reduction in burning sensation was sustained in both the groups, group A seemed to be more effective when compared to group B. The relief from burning sensation in patients treated with spirulina is probably due to the contents of spirulina which contains beta-carotene, phenolic acid, tocopherols, and various micronutrients. [8] A similar finding was reported in 1997. [10] In that study, multiple micronutrient supplements produced relief from burning sensation in 85% patients. Administration of beta-carotene systemically and topically would improve the integrity of the epithelium as well as induce redifferentiation of dysplastic epithelium. [12]

The present study clearly emphasizes that along with habit counseling spirulina has a definitive protective role in reducing clinical signs and symptoms of OSF.


   Conclusion Top


Oral antioxidant spirulina can be used as an adjuvant therapy in the initial management of OSF patients and was well tolerated by oral submucous fibrosis patients without any side effects as reported by the patients in this study. Larger number of patient's sample, with longer period of treatment follow-up, is required to draw further conclusion on the utility of spirulina in the treatment of oral submucous fibrosis.

 
   References Top

1.Pindborg JJ, Sirsat SM. Oralsubmucous fibrosis. Oral Surg Oral Med Oral Pathol 1966;22:764-9.  Back to cited text no. 1
[PUBMED]    
2.Warnakulasuriya S, Johnson NW, van der Waal I. Nomenclature and classification of potentially malignant disorders of the oral mucosa. J Oral Pathol Med 2007;36:575-80.  Back to cited text no. 2
    
3.van der Waal I. Potentially malignant disorders of the oral and oropharyngeal mucosa; terminology, classification and present concepts of management. Oral Oncol 2009;45:317-23.  Back to cited text no. 3
    
4.Tilakaratne WM, Klinikowski MF, Saku T, Peters TJ, Warnakulasuriya S. Oral submucous fibrosis: Review on aetiology and pathogenesis. Oral Oncol 2006;42:561-8.  Back to cited text no. 4
    
5.Kumar A, Bagewadi A, Keluskar V, Singh M. Efficacy of lycopene in the management of oral submucous fibrosis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007;103:207-13.  Back to cited text no. 5
    
6.Rao PK. Efficacy of alpha lipoic acid in adjunct with intralesional steroids and hyaluronidase in the management of oral submucous fibrosis. J Cancer Res Ther 2010;6:508-10.  Back to cited text no. 6
[PUBMED]    
7.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.  Back to cited text no. 7
    
8.Miranda MS, Cintra RG, Barros SB, Mancini FJ. Antioxidant activity of the microalga Spirulina maxima. Braz J Med Biol Res 1998;31:1075-9.  Back to cited text no. 8
    
9.Gupta S, Reddy MV, Harinath BC. Role of oxidative stress and antioxidants in aetiopathogenesis and management of oral submucous fibrosis. Indian J Clin Biochem 2004;19:138-41.  Back to cited text no. 9
[PUBMED]    
10.Maher R, Aga P, Johnson NW, Sankaranarayanan R, Warnakulasuriya S. Evaluation of multiple micronutrient supplementation in the management of oral submucous fibrosis in Karachi, Pakistan. Nutr Cancer1997;27:41-7.  Back to cited text no. 10
[PUBMED]    
11.Canniff JP, Harvey W, Harris M. Oral submucous fibrosis: Its pathogenesis and management. Br Dent J 1986;160:429-34.  Back to cited text no. 11
[PUBMED]    
12.Varghese IP, Hari S. Role of Beta-carotene in the management of oral submucous fibrosis. Published in the 27 th Kerala State Dental Conference; Calicut 1994.  Back to cited text no. 12
    

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Correspondence Address:
Prathima Shetty
Department of Oral Medicine and Radiology, Yenepoya Dental College, Yenepoya University, Mangalore, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-9290.118001

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    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2]

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