Download Effects of Natural Beta-carotene and

10.5005/jp-journals-10011-1221
Thriveni
R et al
RESEARCH
ARTICLE
Effects of Natural Beta-carotene and
Commercially Available Combination of
Beta-carotene, Vitamin E, Vitamin C and
Minerals: A Prospective Comparative Study
1
Thriveni R, 2Praveen AH, 3Mubeen
1
Reader, Department of Oral Medicine and Radiology, AME’s Dental College and Hospital, Raichur, Karnataka, India
2
3
Reader, Department of Oral and Maxillofacial Surgery, AME’s Dental College and Hospital, Raichur, Karnataka, India
Professor and Head, Department of Oral Medicine and Radiology, Government Dental College and Research Centre
Bengaluru, Karnataka, India
Correspondence: Thriveni R, Reader, Department of Oral Medicine and Radiology, AME’s Dental College and Hospital, Raichur
Karnataka, India, e-mail: [email protected]
ABSTRACT
Aim and objective: The purpose of this study was to determine effects of natural beta-carotene and revox in, reducing the oral symptoms of
submucous fibrosis patients, thickness of collagen fibers in submucous fibrosis patients and to correlate the changes in epithelium and
connective tissue.
Materials and methods: The study population consisted of 50 patients with submucous fibrosis divided in two groups randomly. For patients
in group A recived intralesional injection of 0.5 ml hyaluronidase 1500 IU and 0.5 ml hydrocortisone acetate 25 mg/ml were injected in
buccal mucosa bilaterally in alternative week and natural beta-carotene capsule twice daily for 12 weeks along with ice cream stick mouth
exercise. For group B patients intralesional injections and capsule revox were given twice daily for 12 weeks along with ice cream stick
mouth exercise.
Results: There is statistical significant improvement in mouth opening, reduction of burning sensation and decrease in thickness of collagen
bundles were seen in all patients but there was early response in group A than group B.
Conclusion: Our preliminary findings suggest that both groups showed statistical significant results with early response in group A. The
clinical comparison and effectiveness of natural beta-carotene and revox is not statistical significant.
Keywords: Antioxidants, Beta-carotene, Hyaluronidase, Management of submucous fibrosis, Oral submucous fibrosis, Tobacco.
INTRODUCTION
Oral submucous fibrosis is a premalignant and crippling
condition of the oral mucosa, which is found predominantly in
native Asian and Asians settled in other countries.1 The
characteristic features of the disease include submucosal fibrosis
causing to secondary atrophic changes in the epithelium leading
to pale whitish mottled mucosa which feels board like, fibrous
bands in buccal and labial region and restricting mouth opening.
The atrophic epithelium becomes sensitive and vulnerable to
carcinomatous changes.2,3 The exact etiology of oral submucous
fibrosis is not well-understood, however, various factors like
genetic, autoimmune, nutritional and environmental agents are
being studied. Among the environmental factors chewing areca
nut is the most important and persistent finding.1
There have been reports for successful treatment of oral
submucous fibrosis with local injection of placentrex,
hyaluronidase and dexamethesone. In resistant cases, surgical
excision of bands with submucosal placement of fresh human
placental grafts was found to be successful.4
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The concept of antioxidant supplements could prevent or
even cure cancer. In oral submucous fibrosis systemic and
topical administration of beta-carotene will improve the integrity
of the epithelium as well as induce redifferentiation of dysplastic
epithelium. Regular intake of beta-carotene combined with
routine measures will considerably reduce the risk of malignant
transformation.5
Hence, this study aims at the assessment and influence of
natural beta-carotene and combination of beta-carotene and
other antioxidants along with local injections of hyaluronidase
and hydrocortisone in reducing clinical symptoms of burning,
improvement of mouth opening and its effects on collagen.
AIMS AND OBJECTIVES
1. To compare the effects of natural beta-carotene and revox
(beta-carotene, vitamin E, vitamin C and minerals) in
reducing the oral symptoms of submucous fibrosis.
2. To compare the effects of natural beta-carotene and revox
(beta-carotene, vitamin E, vitamin C and minerals) on the
thickness of collagen fibers in submucous fibrosis.
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Effects of Natural Beta-carotene and Commercially Available Combination of Beta-carotene, Vitamin E, Vitamin C and Minerals
3. To correlate the changes brought about by the natural betacarotene and revox (beta-carotene, vitamin E, vitamin C
and minerals) in epithelium and connective tissue.
MATERIALS AND METHODS
This study was planned and conducted in the Department of
Oral Medicine and Radiology, Government Dental College and
Hospital, Bengaluru.
Selection of Patients
The patients for the study were selected from the outpatients
who visited the Department of Oral Medicine and Radiology,
Government Dental College and Hospital, Bengaluru. A detailed
case history about habits was taken followed by a thorough
clinical examination. The diagnosis was made based on the
WHO definitions for oral submucous fibrosis.6 Fifty patients
who were suffering from oral submucous fibrosis were selected
for this study in the age groups of 20 to 40 years.
Recording the Data and Clinical Examination
After explaining about the study to the subject, an informed
consent was obtained and a structured proforma was
administered and detailed case history of the patients was
recorded.
Inclusion Criteria
1. Patients with a habit of chewing betel nut and other
commercially available products containing betel nut,
tobacco, etc. for more than 1 year.
2. Symptoms of burning sensation in the mouth for spicy food
and without spicy food, patient with progressive difficulty
in opening the mouth, patients with inability to protrude
the tongue and stiffness of the oral mucosa.
3. Patients with mucosal signs of blanching, palpable vertical
fibrous bands in the buccal mucosa.
Exclusion Criteria
1. Patients who are undertreatment for submucous fibrosis
previously.
2. Patients with submucous fibrosis having diabetics,
hypertension and pregnant ladies were excluded from the
study.
3. Patients with total trismus, chronic ulcers and difficulty in
swallowing were excluded.
4. Patients with temparomandibular joint problems and
pericoronitis of the lower third molars.
Patients who were selected for the study were categorized
in different grades according to the grading of Gupta Dinesh
Chandra et al.7
Biopsy of the Lesion
After thorough clinical examination, the patients were subjected
for biopsy. Right buccal mucosa was selected as a standard site
for biopsy in all patients. Punch biopsy was done under
2% local anesthesia and subjected to following staining
methods.
1. Hematoxyline and Eosine stain
2. Van-Gieson’s stain
3. Masseon‘s Trichrome stain
4. Verhoff’s stain
Study Duration and Treatment Procedure
The treatment plan was followed for a period of 3 months. All
the patients with palpable fibrous bands in the buccal mucosa
were randomly divided into two groups. For all the patients
interincisal distance measured with the help of slide calipers
before and after treatment (Figs 1 and 2) and biopsy was done
before treatment and 3 weeks after treatment (Figs 3 and 4).
Patients were recalled every week on appointment basis for
3 months.
For patients in group A intralesional injection of
hyaluronidase 1500 IU mixed in 1 ml of lignocaine solution
and injected about 0.5 ml in the buccal mucosa bilaterally and
intralesional injection of hydrocortisone acetate 25 mg/ml about
0.5 ml in the buccal mucosa bilaterally was given alternatively
per week with natural beta-carotene capsules for 12 weeks and
ice cream stick mouth exercise with increase in one stick every
alternate day.
For group B patients along with intralesional injection of
hyaluronidase and hydrocortisone as before, a capsule revox
was given for 12 weeks along with ice cream stick mouth
exercise.
After systemic administration of natural beta-carotene and
revox and intralesional injection of hydrocortisone and
hyaluronidase, no patient reported back with symptoms of
vomiting, gastritis, diarrhea and irritation or swelling at the site
of injection.
OBSERVATION AND RESULTS
The study was conducted on 50 patients of both the genders of
different age groups. All patients with submucous fibrosis
showed involvement of right and left buccal mucosa and other
parts of the oral cavity. Among the study group of 50 patients,
few patients had difficulty in mouth opening, few had burning
sensation and some patients had both as shown in Graphs 1 and
2 and Table 1. During the period of treatment, in all the patients’
reduction of burning sensation was seen in different stages which
were shown in Table 2, Graphs 3 and 4.
In this study comparison of groups A and B was done. A
test of significance students t-test resulted in a value p > 0.05
(t = 0.916) which is not significant (because p < 0.05), this
indicates both the groups were similar before the treatment.
Different treatment modalities were carried out for both the
groups, after treatment a test of significant paired t-test resulted
in a value for mouth opening parameter p < 0.001 (group A
t = 16.4754 and group B 18.3351) and for histological
parameters p < 0.001 (group A 8.8092 and group B 11.111)
Journal of Indian Academy of Oral Medicine and Radiology, October-December 2011;23(4):554-58
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Thriveni R et al
Fig. 1: Preoperative picture
Fig. 2: Postoperative picture
Fig. 4: Postoperative (H&E stain)
To know the effect of natural beta-carotene and revox in
improvement of mouth opening, a test significance of ANOVA
has carried out which shows:
Group A: Grade III 1.33
Grade IV 1.59
Group B: Grade III 1.3882
Grade IV 1.7625
Which is not significant (because p > 0.05) indicates both
the treatment in both grades effected similarly.
To know the effect of natural beta-carotene and revox in
reducing the thickness of collagen bundles a test of significance
of ANOVA was done with a resultant mean values as follows:
Group A: Grade III 1.02
Grade IV 0.68
Group B: Grade III 1.0324
Grade IV 0.6875
Which indicates both the treatments affected in a similar
way in both the grades,but respect of natural beta-carotene or
revox grade III, patients responded well than grade IV (p < 0.01).
DISCUSSION
Fig. 3: Preoperative (H&E stain)
which was highly significant indicating both the groups
responding very well for the treatment.
To compare the effectiveness of treatment in between the
groups, after treatment students t-test was done which resulted
in a value p > 0.05 (group A, t = 1.507 and group B, t = 1.396
and for mouth opening parameters t = 0.1171) which is not
significant indicates both the groups showed similar response.
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Oral submucous fibrosis has been attributed to the habit of betel
nut chewing which is predominant among the Indian
population.8 It is well documented that oral submucous fibrosis
is a precancerous condition9,10 and consequently possess a
challenge to medical profession in general and oral medicine
specialist in particular.
In our study, there was predominant occurrence in males
than females with age group of 20 to 40 years which is because
of use of commercially available packed pan masala among
young males. Study reports support the hypothesis that the
relative risk of developing submucous fibrosis directly
proportional to exposure to various harmful substance in a given
time to that of total duration of exposure.4
In this study, intralesional injection of hydrocortisone
acetate 25 mg/ml and hyaluronidase was injected in the buccal
mucosa bilaterally in alternative week for 3 months.
Histopathological examination of biopsy specimen after
treatment for all patients showed remarkable reduction of
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Graph 1: Symptoms of group A patients
Graph 2: Symptoms of group B patients
Table 1: Symptoms
Groups
Total
Patient
A
B
Difficulty in mouth opening
Burning sensation
Both
Male
Female
Total
Male
Female
Total
Male
Female
Total
5
5
1
1
6
6
2
1
1
1
3
2
14
16
2
1
16
17
Graph 4: Reduction of burning sensation in group B patients
Graph 3: Reduction of burning sensation in group A patients
Table 2: Reduction of burning sensation
Groups
Total reduction of burning sensation
2nd week
Total
Patients
A
B
3rd week
4th week
5th week
6th week
Male
Female
Male
Female
Male
Female
Male
Female
Male
Female
4
0
0
0
5
0
0
0
7
10
3
0
0
6
0
1
0
1
0
1
inflammatory cells, thickness of collagen bundles, which is
related to effect of corticosteroids and hyaluronidase.
The mode of action of hyaluronidase is thought to be
destruction of collagen11 because it has been seen that breaking
down of hyaluronic acid and collagen fibers in patients with
oral submucous fibrosis was attacked rapidly by hyaluronidase
when compare to the normal patients. It lowers the viscosity of
intercellular cementing substance and also decreases collagen
formation. The locally given steroids act by opposing the acting
of soluble factors released by sensitized lymphocytes following
activation of nonspecific antigens and they function as
immunosuppressive agents. Also the inflammatory reaction at
Journal of Indian Academy of Oral Medicine and Radiology, October-December 2011;23(4):554-58
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Thriveni R et al
the site is suppressed thereby fibrosis is prevented by a decreased
in fibroblastic proliferation and decreased in deposition of
collagen.7
In our study we have found statistical significant
improvement in the burning sensation and mouth opening in all
patients especially in grade III patients. This could be explained
because of various factors including intralesional injection of
corticosteroids and hyaluronidase along with systemic
administration of spirulina (natural beta-carotene) and revox.
Spirulina is a blue-green algae which contains natural
antioxidants, such as beta-carotene, vitamin E, selenium,
vitamin C, etc.12,13 They act by effectively quench the hazardous
free radicals, which initiate carcinogenesis. Beta-carotene also
has immunoregulating properties that might retard the
development of cancer cells and also increases the number of
circulating lymphocytes, enhances the proliferation and
induction of cytotoxic T cells and increases the number of helper
T cells and tumor necrosis factor.5,14
Considerable data support the concept of synergistic effect
among the antioxidants, beta-carotene, ascorbic acid and alphatocopherol are free radical scavengers with different subcellular
distributions and jointly participate in cancer prevention by
immunosurveillance against tumor.5,14
In the recent studies following treatment modalities have
been used to treat the patients with oral submucous fibrosis:
1. Interferon gamma—intralesional injection of 0.01 to 10.0
U/ml, three times a day for 6 months.15
2. Pentoxifylline—400 mg three times a day for 7 months.16
3. Lycopene—8 mg twice a day for 2 months.17
In our study, clinical comparative effect of natural betacarotene and revox, is not statistically significant but irrespective
of use of those, there is statistical significant improvement in
grade III patients than grade IV patients in both the groups.
Natural beta-carotene and revox are both freely available in
the market and they have almost similar biological effects with
no adverse effects. Hence, it becomes the clinician’s choice to
select spirulina or revox to improve nutritional status, immune
status and prevention of cancer in patients with submucous
fibrosis.
CONCLUSION
Though this a preliminary study but one can draw to certain
extent the following conclusion by its results:
• There is a statistical significant improvement in the mouth
opening, reduction of burning sensation and decrease in the
thickness of collagen bundles were seen in all patients, but
there was early response in group A than group B patients.
• The clinical comparison and effectiveness of natural betacarotene and revox is not statistically significant.
This study has given scope for further studies with larger
sample size and use of electron microscopic study for tissue
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changes correlated with blood samples of natural beta-carotene
and revox are required to conclude above results.
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