International Medical Journal Vol. 20, No. 3, pp.

392 - 394 , June 2013

LETTERS TO THE EDITOR
Novel Material in the Treatment of Minor Oral Recurrent
Aphthous Stomatitis
Daddy Suradi Halim, Nor Izzaty Binti Abdul Khalik, Haslina Taib,
Abdullah Pohchi, Akram Hassan, Mohammad Khursheed Alam
ABSTRACT
Background: There are many medications and traditional remedy in treating mouth ulcers. This study aimed to compare the
effectiveness between turmeric and triamcinolone in treating minor recurrent aphthous ulcer in oral cavity.
Materials and Methods: The effectiveness of healing ulcer measured using two parameters, which are the ulcer size and pain
score. Twenty patients (n = 20) with minor recurrent aphthous stomatitis were volunteered to join the study, with no known
medical illness. Subjects were divided into two groups. One group received triamcinolone acetonide (0.1%) and the other group
received turmeric powder. The subjects were required to apply the medication twice per day. Ulcer size and pain were been
measured on treatment days 1 and 5. Data were analyzed using t test for independent sample.
Results: No significant differences were been found between the two groups studied. In conclusion, the two treatments
applied had similar effectiveness as they both relieved pain and reduced the size of recurrent aphthous ulcers.
Conclusion: Still, as an alternative, the turmeric can be used for treating minor recurrent aphthous ulcer meanwhile the tri-
amcinolone cannot be used in long term management in treating the ulcer.
KEY WORDS
mouth ulcers, turmeric, triamcinolone
Received on July 2, 2012 and accepted on October 4, 2012
School of Dental Sciences, Universiti Sains Malaysia, Health Campus
16150 Kubang Kerian, Kelantan, Malaysia
Correspondence to: Daddy Suradi Halim
(e-mail: daddy@kb.usm.my)
392
INTRODUCTION
Recurrent aphthous stomatitis (RAS; aphthae; canker sores) is
typified by a common oral mucosal disorder that is characterized by
multiple, recurrent, small, round, or ovoid ulcers with circumscribed
margins, erythematous haloes, and yellow or grey floors that present
first in childhood or adolescence (Scully et. al, 2008). The factors
that predispose to RAS, such as behavioral factor in smoking (Noor
NM et. al. 2008) and stress, trauma, food and nutrients deficiency,
systemic disease (e.g: anemia, Behcet's disease, Chron's disease), and
medication (e.g. NSAIDs, -blockers, Nicorandil, Alendronate)
(Chattopadhyay, 2011).
There is no curative treatment for RAS. There have been few ran-
dom control trials (RCTs) of treatment for RAS. But, treatment
options for now are no treatment, palliative approach (e.g. Topical
agents: home remedies, over-the-counter medications, prescribed
analgesics, cauterizing agents), anti-inflammatory and antimicrobial
agents, immunomodulation (e.g. Topical such as corticosteroid
creams, ointments, gels, rinses; intralesional (perilesional) corticos-
teroid injections, and systemic such as corticosteroids, nonsteroidal
immunosuppressive agents, anti-inflammatory agents), or combined
therapy, for examples, topical combines with systemic agents or sys-
temic agents in combination (Eisenberg, 2003).
Turmeric, the powdered dry rhizome of the plant Curcuma longa
Linn, has been widely used as colouring agent, a spice and in the
treatment of inflammatory conditions and other diseases. Curcumin
(diferuloylmethane), the yellow pigment in turmeric is the major
antioxidant and anti-inflammatory substance in turmeric. (Thapliyal
et. al, 2002). The possible mechanism of action of curcumin involves
the decreased rate of release and metabolism of arachidonic acidin-
volving diminished activities of phosholipaseA2, cyclooxygenase,
lipooxygenase, and also by inhibiting the production of reactive oxy-
gen and nitrogen species, which act as intermediates in many signal
transduction pathways (Saja et. al, 2007).
Several other experimental studies have revealed that curcumin is
a potent antioxidant for the prevention or treatment of inflammatory
processes (Strasser et. al, 2005).
Studies showed that curcumin could down regulate the expres-
sion of interleukin (IL)-6 protein, TNF, and various other chemokines
which could suppress inflammation through multiple pathways
(Aggarwal et. al, 2009).
Turmeric is used to some extent as a stomachic, tonic, blood puri-
fied, treating cold, and antiparasitic for many skin affections.
Externally, it has been applied to indolent ulcers, inflamed joints and
have antiseptic properties. It is an antacid and can act as an antispas-
modic. The used of turmeric in dentistry has been reported for treat-
ing toothache, gingivitis, periodontitis and others (Gupta et. al, 1998;
Chartuvedi, 2009). It has also been studied for anti-ulcer activity in
acute ulcer model in rat by preventing glutathione depletion, lipid
peroxidation and protein oxidation (Swarnakar et. al, 2005).
However, still there is no study has been done for using turmeric
to treat minor RAS. This study will explore its efficacy and compare
with the common medication used for this ulcer, which is the triamci-
C 2013 Japan International Cultural Exchange Foundation
& Japan Health Sciences University
393
nolone.
MATERIALS AND METHODS
This study is a single blinded randomized clinical trial. Twenty
students of USMKK who volunteered and presented with minor trau-
matic ulcer in the oral cavity were examined.
Inclusion criteria
- Healthy, with no systemic disease (diabetes) and immunod-
eficiency state
- Age 18 years old and above
- Have ulcer size < 10 mm, not more than 3 days
- Not taking antibiotic 3 months prior to the study
- Are not on analgesic or antiseptic
Exclusion criteria
- Smoker
- Under systemic or topical corticosteroid therapy
- Pregnant women or lactating mothers
Ethical approval was obtained from the Research and Ethics
Committee, Universiti Sains Malaysia. The 20 subjects were divided
equally into two groups and had been given different medication for
the minor aphthous ulcer. Subjects for group 1 were been given
turmeric, while the group 2 received the triamcinolone. The tools
used in this research were the pain score and the size of the ulcer.
The Visual Analogue Score (VAS) was been used to assess the pain
score and the ulcer size was been measured by sliding caliper. Both
ulcer size and pain score were being taken on the day 1. The subjects
were been instructed to apply the medicament for five minutes, twice
a day for five consecutive days. On the day 5, the ulcer size and the
pain score had been assessed again.
Statistical Package for Social Science version 18.0.0 statistical
software was used for data entry and data analysis. Descriptive statis-
tic of the study subject such as means and standard deviation (SD)
was calculated. The collected data analyzed by SPSS version 18.0.0.
Significant differences between two groups were analyzed using
independent t test. P < 0.05 was considered statistically significant.
RESULT
Pain score and ulcer size difference between day 1 and day 5
were analysed using independent t test.
Based on the result in table, both variables have P > 0.05 indicate
there are no significant difference between turmeric and triamci-
nolone for the treatment of minor recurrent aphthous ulcer. Even
though the differences were not significant, but for mean comparison,
the triamcinolone has greater value of mean for ulcer size indicate
turmeric is better in reducing the size of the ulcer. Meanwhile, for
pain score, the turmeric is the better medicament for relieving the
pain of the ulcer compare to triamcinolone.
DISCUSSION
In this study, turmeric as a novel material can be used as an alter-
native medicament for the treatment of minor recurrent aphthous
ulcer. It revealed that the turmeric helps in reducing the pain of the
ulcer. A study (A. Poongodi et. al, 2011) stated that the turmeric help
in wound healing. According to Amrutesh (2011), the benefits of
turmeric are analgesic, antibacterial, anti-inflammatory, anti-tumor,
anti-allergic, antioxidant, antiseptic, antispasmodic, appetizer, astrin-
gent, cardiovascular, carminative, cholagogue, digestive, and diuret-
ic. Other studies showed that curcumin could downregulate the
expression of interleukin (IL)-6 protein, TNF, and various other
chemokines. Other studies showed that curcumin inhibited the pro-
duction of IL-8, MIP-1a, MCP-1, IL-1 and TNF-a induced by
inflammatory stimuli in human peripheral blood monocytes and alve-
olar macrophages. Curcumin downregulates the expression of the
Halim D. S. et al.
Table 1. The pain score and ulcer size of all subjects all
the way through the study using turmaric
Subjects Pain score Ulcer size
Day 1 Day 5 Day 1 Day 5
1 7 0 11.775 1.570
2 4 0 18.847 3.140
3 2 2 7.065 .785
4 7 3 1.256 2.119
5 8 3 1.036 2.355
6 6 0 24.727 4.945
7 5 0 4.906 .785
8 7 0 25.504 4.906
9 5 2 10.001 12.010
10 6 5 21.980 33.079
Mean 5.7 1.1 12.709 6.569
Std. Deviation 1.767 1.287 9.429 9.883
P value .000 .095
Table 2. The pain score and ulcer size of all sub-
jects all the way through the study using
triamcinolone
Subjects Pain score Ulcer size
Day 1 Day 5 Day 1 Day 5
11 4 0 30.222 9.734
12 4 0 7.065 .785
13 4 0 2.833 .635
14 4 0 5.652 1.413
15 7 0 1.766 1.538
16 1 0 8.548 .502
17 4 0 13.878 6.868
18 7 0 22.050 9.074
19 5 0 40.035 1.766
20 4 8 4.333 8.949
Mean 4.40 .80 13.638 4.126
Std. Deviation 1.713 2.530 12.994 3.983
P value .006 .036
Table 3. Comparison of pain score and ulcer size differ-
ences between turmeric and triamcinolone
Variable Ulcer size Pain score
Group 1 Group 2 Group 1 Group 2
Mean 23.7042 51.4677 4.6 3.6
SD 82.05465 60.71060 2.066 3.169
P-value 0.401 0.414
394
NF- B-regulated gene products such as COX-2, TNF, 5-LOX, IL-1,
IL-6, IL-8, MIP-1a, adhesion molecules, C-reactive protein (CRP),
CXCR-4, and others. Curcumin has also been reported to bind to
COX-2 and 5-LOX and to inhibit their activity. Recent work has
shown that curcumin directly binds to IkBa kinase needed for NF- B
activation. Studies also demonstrate that curcumin is a potent
inhibitor of STAT 3, another transcription factor through which
proinflammatory cytokine IL-6 mediates its effects. Thus curcumin
could suppress inflammation through multiple pathways (Aggarwal
et. al, 2009).
It has also been studied for anti-ulcer activity in acute ulcer
model in rat by preventing glutathione depletion, lipid peroxidation
and protein oxidation. Denudation of epithelial cells during damage
of gastric lumen is reversed by curcumin through re-epithelialization.
Furthermore, both oral and intraperitoneal administration of curcum-
in blocked gastric ulceration in a dose dependent manner. It acceler-
ated the healing process and protected gastric ulcer through attenua-
t i on of MMP-9 act i vi t y and amel i orat i on of MMP-2 act i vi t y
(Swarnakar et. al, 2005). Other study suggest herbal medicine offer a
safer, and often an effective, alternative treatment for pain relief,
especially for long-term use. Curcumin, long been used in both
Ayurvedic and Chinese medicines as an anti-inflammatory agent, a
treatment for digestive disorders, and to enhance wound healing.
Several clinical trials have demonstrated curcumin's antioxidant, anti-
inflammatory, and antineoplastic effects. Most studies to date has
been performed in animals, but given the centuries of use of curcum-
in, as well as its now demonstrated activity in the NF- B, COX-1,
and COX-2 inflammatory pathways, it may be considered a viable
natural alternative for the treatment of inflammation (Maroon et. al,
2010).
In animal study, curcumin increased cellular proliferation and
collagen synthesis at the wound site, as evidenced by increase in
DNA, total protein and type III collagen content of wound tissues.
Curcumin treated wounds were found to heal much faster as indicated
by improved rates of epithelialisation, wound contraction and
increased tensile strength which were also confirmed by histopatho-
logical examinations. Curcumin treatment was shown to decrease the
levels of lipid peroxides (LPs), while the levels of superoxide dismu-
tase (SOD), catalase (CAT), glutathione peroxidase (GPx), activities
were significantly increased exhibiting the antioxidant properties of
curcumin in accelerating wound healing. Better maturation and cross
linking of collagen were observed in the curcumin treated rats, by
increased stability of acid-soluble collagen, aldehyde content, shrink-
age temperature and tensile strength. The results clearly substantiate
the beneficial effects of the topical application of curcumin in the
accel erat i on of wound heal i ng and i t s ant i oxi dant effect
(Panchatcharam et. al, 2006).
For long-term usage of turmeric, a study done by Joshi (2003)
shows that there was no effect of turmeric oil(TO), in two doses, on
pulse and blood pressure and no side effects in acute tolerability
study on day 1. There was no effect of TO intake on weight, blood
pressure, symptoms and signs up to 12 weeks. There was no clinical,
haematological, renal or hepatic-toxicity of TO at 1 month and 3
months. Serum lipids did not show significant change except in one
volunteer (reversible).
CONCLUSION
The turmeric is an herbal medicine that easily available and inex-
pensive make it more appealing as a therapeutic agent.
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Oral Recurrent Aphthous Stomatitis