Efficacy of aloe vera and triamcinolone acetonide 0.1% in recurrent aphthous stomatitis: A preliminary comparative study

Versha R Giroh; Manjula Hebbale; Amit Mhapuskar; Darshan Hiremutt; Priya Agarwal

doi:10.4103/jiaomr.jiaomr_203_18

ORIGINAL ARTICLE

Year : 2019 | Volume : 31 | Issue : 1 | Page : 45-50

Efficacy of aloe vera and triamcinolone acetonide 0.1% in recurrent aphthous stomatitis: A preliminary comparative study

Versha R Giroh, Manjula Hebbale, Amit Mhapuskar, Darshan Hiremutt, Priya Agarwal
Department of Oral Medicine and Radiology, Bharati Vidyapeeth Deemed University Dental College and Hospital, Pune, Maharashtra, India

Date of Submission	05-Dec-2018
Date of Acceptance	28-Feb-2019
Date of Web Publication	23-Apr-2019

Correspondence Address:
Versha R Giroh
Department of Oral Medicine and Radiology, Bharati Vidyapeeth Deemed University Dental College and Hospital, Pune - 411 043, Maharashtra
India

Source of Support: None, Conflict of Interest: None

Check

DOI: 10.4103/jiaomr.jiaomr_203_18

Abstract

Introduction: Aloe vera has various pharmacological actions due to which it has been selected as an alternative treatment modality in treating various oral diseases. It has antibacterial, antifungal, antiinflammatory, antioxidant, antitumor, and immune boosting. It has been used for the management of oral lesions such as oral lichen planus, oral submucous fibrosis, radiation-induced mucositis, burning mouth syndrome, xerostomia, recurrent aphthous ulcers. Aim: The aim of this study is to the compare the effects of the topical aloe vera gel and triamcinolone acetonide 0.1% in patients with minor ulcers of aphthous stomatitis. Materials and Methods: Thirty-four patients presenting with clinical signs and symptoms of aphthous stomatitis were included for the randomized single blinded study after informed consent. Group A patients received topical aloe vera gel (Forever Bright Aloe vera Gel), and Group B patients received topical triamcinolone acetonide 0.1% (kenacort oral paste) three times a day for 7 days or till the ulcer heals completely. The parameters such as the size of the ulcer, burning sensation, and pain were recorded at each visit. Results: In this study, kenacort oral paste was found to be effective than aloe vera in wound healing (measured by the diameter of ulcer). In contrast, aloe vera gel had a better response in terms of pain and burning sensation. Conclusion: Aloe vera has a wide spectrum of unique properties and uses. It is a promising agent in treating oral lesion in the field of oral medicine. It can be used as an alternative medicine and in patients who are allergic to steroid medication.

Keywords: Aloe vera, aphthous stomatitis, burning sensation, triamcinolone acetonide 0.1%, wound healing

How to cite this article:
Giroh VR, Hebbale M, Mhapuskar A, Hiremutt D, Agarwal P. Efficacy of aloe vera and triamcinolone acetonide 0.1% in recurrent aphthous stomatitis: A preliminary comparative study. J Indian Acad Oral Med Radiol 2019;31:45-50

How to cite this URL:
Giroh VR, Hebbale M, Mhapuskar A, Hiremutt D, Agarwal P. Efficacy of aloe vera and triamcinolone acetonide 0.1% in recurrent aphthous stomatitis: A preliminary comparative study. J Indian Acad Oral Med Radiol [serial online] 2019 [cited 2022 Jul 3];31:45-50. Available from: https://www.jiaomr.in/text.asp?2019/31/1/45/256898

Introduction

Healthy oral cavity is a reflection of good health. Oral mucosa, being the lining of the oral cavity performs various functions such as protection. Any alteration in the integrity of the oral mucosa can lead to discomfort or pain, affecting the overall health of an individual.

Ayurveda is a traditional natural system of medicine that has started to gain popularity now. Aloe vera is a very important component of this medicinal system as it poses multiple pharmacological values. The Egyptians called Aloe Vera as “the plant of immortality.”^[1]

Aloe vera belongs to the Liliaceae family. Among 360 species, only two species are grown commercially: Aloe barbadensis Miller and Aloe aborescens.^[2] The leaves contain colorless mucilaginous gel (98–99% water and 1–2% active compounds). Aloe vera gel contains the following components.^{[3],[4],[5],[6]}

Anthraquinones—aloin, barbaloin, anthranol, etc.
Vitamins such as B1, B2, B6, C, choline, folic acid
Nonessential vitamins—histidine arginine hydroxyproline, aspartic acid, glutamic acid, proline, uric acid, glycine, alanine, tyrosine
Essential amino acids such as lysine, valine, leucine, isoleucine, phenylalanine, methionine for the repair and growth.
Inorganic compounds—calcium, sodium, chlorine, manganese, zinc, copper, magnesium, iron.

The biological effects of the above-mentioned components are the following:^[1],[7],[8]

Healing properties
Antiinflammatory actions
Antiviral action
Antitumor activity
Moisturizing and antiaging properties
Antiseptic properties.

Due to the various biological and pharmacological properties, aloe vera has been used for the treatment of recurrent aphthous stomatitis, herpes simplex, and herpes zoster infection.^{[9],[10],[11],[12]} Oral lichen planus,^{[13],[14],[15],[16],[17]} oral submucous fibrosis,^[18],[19] radiation-induced mucositis,^[20] burning mouth syndrome,^[21] candida-associated denture stomatitis,^[22] xerostomia,^[23] periodontitis.^[24]

Aloe vera is available in various forms for topical application such as toothpaste, mouthwash, gel, topical spray and juice for systemic usage.^[25]

Recurrent aphthous stomatitis (RAS) is an ulcerative disease that most often occurs in an otherwise healthy individual, and is characterized by recurrent, single, or multiple ulcerations involving labial mucosa, buccal mucosa, and floor of mouth.^[26] There are three types-minor, major, and herpetiform.

Minor aphthous ulcer is characterized by painful round, oval shallow ulcers, regular in outline, usually less than 10 mm in diameter with a grayish white pseudomembranous floor surrounded by a thin zone of erythematous halo [Figure 1]. Major aphthous ulcers are similar to minor ulcers but are larger than 10 mm in diameter. Herpetiform ulcers are multiple small clusters of pinpoint ulcers, tend to be small and numerous. Treatment modalities include topical corticosteroids, local anesthetics, tetracycline, levamisole, and laser therapy. Corticosteroids are the main stay for treatment which includes topical, systemic or intralesional approach. Newer drugs have the ability to stick firmly to the wet, moving mucous, forming a protective film over the ulcer, leading to faster pain relief and rapid healing. The commercially available paste is to be applied 2–3 times a day. Other topical corticosteroids include triamcinolone acetonide, clobetasol propionate 0.05%, and fluocinonide 0.05%.

Figure 1: Intraoral image showing minor aphthous ulcer on lower labial mucosa

Click here to view

There are very few studies done showing the effects of aloe vera on recurrent aphthous stomatitis. Therefore, the aim of this study is to the compare the effects of the topical aloe vera gel and triamcinolone acetonide 0.1% in patients with minor ulcers of aphthous stomatitis.

Materials and Methods

This study was conducted in the department of Oral Medicine and Radiology. This randomized single-blinded study consisted of 34 clinically diagnosed individuals with minor aphthous stomatitis who gave an informed consent following protocols approved by Institutional Ethics Committee. The entire sample was divided randomly into two groups with 17 patients each with an age range of 20–50 years. Group A patients received topical aloe vera gel (Forever Bright Aloe vera Gel) three times a day for 7 days or till the ulcer heals completely. Group B patients received topical triamcinolone acetonide 0.1% (kenacort oral paste) three times a day for 7 days or till the ulcer heals completely. The selected samples met the following inclusion and exclusion criteria.

Inclusion criteria

Clinically diagnosed patients with recurrent aphthous stomatitis in the oral cavity measuring ≤5 mm in size and who gave a written consent for participation were considered in the study. Patients who gave a positive history of developing similar ulcers on the oral mucosa during a period of 3–4 months and ulcers less than 48 hours were included in the study. Only single ulcer was considered for the study.

Exclusion criteria

Patients with a history of associated systemic illness, cases of recurrent aphthous stomatitis (major), multiple RAS lesions and herpetic form lesions, and smoking were excluded from the study. In addition, patients with history of hypersensitivity to aloe vera were not considered.

To measure the effectiveness of aloe vera gel in Group A, patients were advised to apply topical aloe vera gel on oral ulcer three times a day for 7 days/till ulcer heals completely. Moreover, 5 mg of aloe vera gel was quantified using a graduated scoop, and given for a period of 3 days. Group B patients were advised to apply triamcinolone acetonide 0.1% (kenacort oral paste) on oral ulcers three times a day for 10 days/till ulcer heals completely. Kenacort oral paste was given as a 5 g tube to the patients for a period of 10 days/till the ulcer heals completely. Equal amount of ointment were to be applied for a period of 3 days. All the patients were instructed to avoid solid and liquid diet for 30 min after the application of both the medicaments. Patients were recalled on the third day and were given the medicament again for a period of 4 days with the above-mentioned instructions. Patients were recalled on the seventh day for evaluation. If the ulcer did not heal by the seventh day, additional dose of medicine was given again for a period of 3 days with the above-mentioned instructions and was asked to come on the tenth day/till the ulcer heals completely for evaluation.

Clinical parameters

The following clinical parameters were recorded and assessed.

Size of ulcers (in mm)—Size of ulcer was recorded using a calibrated dental probe with millimeter marking, on every third day and seventh day/till the ulcer heals completely after starting the treatment
Pain—The intensity of pain was determined using a numerical rating Visual Analogue Scale (0–10)
Burning Sensation—The intensity of burning sensation was determined using Visual analogue scale (0–10).

Statistical analysis

The mean and standard deviation for the size of ulcer, VAS scores for pain, and burning sensation were measured using the using Independent Student 't' Test. A P < 0.05 was considered statistically significant. Because patients were randomly allocated in either the test or the control group, their mean age and the female-to-male ratios, which might be two important factors affecting pain perception and RAS healing process, were not significantly different.

Results

This study consisted of 34 patients, divided into two groups (Group A and Group B) with 17 patients each. All 34 patients succeeded in completing the study. The male-to-female ratio in the aloe vera group was 0.9:1 whereas 1.1:1 in the kenacort group, which was not found to be statistically significant [Figure 2]. This ensured the comparability of treatment among the study population. Patients with single ulcer in the oral cavity were only considered for the study.

Figure 2: The gender-wise distribution of study population among the two study groups

Click here to view

Site of ulcer

The most common site in the entire sample was labial mucosa (20 out of 34), followed by buccal mucosa (4 out of 34), lateral border of tongue (4 out of 34), alveolar mucosa (3 out of 34), and the attached mucosa (3 out of 34). The labial mucosa was the most common site identified in both the groups with maximum being in Group B (76.5%) as compared to Group A (41.2%), which was found to be statistically significant (P < 0.05). All ulcers were diagnosed clinically by an oral medicine specialist [Figure 3].

Figure 3: The site-wise distribution of study population among the two study groups

Click here to view

Size of the ulcer

The size of the ulcer ranges from 1 to 5 mm in diameter in the entire sample. The mean and standard deviation (SD) were compared for the size of ulcer. The mean size of ulcer in patients receiving aloe vera gel at the time of visit 1(i.e., 0^th day) was 2.9 mm; whereas, at visit 3 (i.e., 7^th day), the ulcer had disappeared completely. The mean size of ulcer receiving kenacort oral paste at the time of visit 1 was 3.2 mm; whereas, at visit 3, the ulcer had disappeared completely. The reduction in the size of ulcer was maximum in Group B, that is, patients receiving the kenacort oral paste, at visit 2 (0–3 day) as compared to Group A, that is, patients receiving the aloe vera. The difference was not statistically significant [Figure 4].

Figure 4: Comparison between the size of ulcer among the two study groups

Click here to view

VAS score for pain

The mean VAS score for pain in patients receiving aloe vera gel at the time of visit 1 was 4.7, reduced to 0 at visit 3. The mean VAS score for pain in Group B, that is, patients receiving kenacort oral paste at the time of visit 1 was 2.35, reduced to 0 at visit 3. The change in VAS scores for pain at visit 2 (0–3 day) in Group A (patients receiving aloe vera gel) was more as compared to Group B, and the difference was statistically significant (P < 0.05) [Figure 5].

Figure 5: Comparison between VAS scores for pain between two study groups

Click here to view

VAS score for burning sensation

The mean VAS score for burning sensation in Group A, that is, patients receiving aloe vera gel at the time of visit 1 was 4.5, reduced to 0 at visit 3. The mean VAS score for pain in Group B, that is, patients receiving kenacort oral paste at the time of visit 1 was 2.11, reduced to 0 at visit 3. The change in VAS scores for burning sensation at visit 2 (0–3 day) in Group A, that is, patients receiving aloe vera group was more as compared to Group A, and the difference was statistically significant (P < 0.05) [Figure 6].

Figure 6: Comparison between VAS scores for burning sensation between two study groups

Click here to view

Interpretation of the Results

In this study, kenacort oral paste was found to be effective than aloe vera in terms of wound healing (measured by the diameter of ulcer); whereas, aloe vera gel had a better response in terms of pain and burning sensation.

The topical side effects may manifest as redness, burning, stinging sensation, and rarely generalized dermatitis in sensitive individuals.

No adverse effects of aloe vera gel as well as kenacort oral paste were reported in the study. Aloe vera gel was well tolerated by all the patients.

Discussion

This study showed the effectiveness of aloe vera in the treatment of minor aphthous ulcers. Aloe vera being a natural product is widely used as an alternative treatment for many oral lesions.

In this study, kenacort was found to be effective when compared to aloe vera in terms of ulcer size reduction that is in accordance with Bhalang et al.,^[10] who evaluated the effectiveness of acemannan (extract of aloe vera) in oral aphthous ulceration. He found that there was a reduction in the size of the ulcer and the associated pain after the topical application of aloe vera for 7 days, but results were inferior to 0.1% triamcinolone acetonide. The reasons for the wound healing effect of aloe vera could be due to its ability to increase the epithelial cell migration. Glucomannan and gibberellin (present in the extract of aloe vera) promote the collagen synthesis. It has been found that the topical application of aloe vera increases the synthesis of hyaluronic acid and dermatan sulfate in the granulation tissue of the wound, promoting the wound healing.^[1] In addition, aloe vera increases the wound closure rate and tensile strength of the wound. Aloe vera gel forms a protective coating on the affected areas and helps in healing wounds, fastens the healing rate, and relieves pain.

There are very few studies in relation to the treatment of aphthous ulcer using aloe vera gel. Garrick JJ et al.^[9] tested the effectiveness of a gel containing silicon dioxide, aloe vera, and allantoin in the healing of recurrent aphthous ulcers. A preliminary study (Study I) was carried out to indicate the effect of each active substance and each combination. The result showed that the statistical differences in the durations of lesions (P = 0.017) were present when all three substances were included in the gel. In the next study (Study II), additional subjects were divided into two groups: one used a control gel with silicon dioxide and the other a gel with all three active substances. Study II found no statistical differences in the parameters when the two groups were compared. In Study III, a modified crossover design was used with the subjects of Study II, and a significant difference was found in lesion-free intervals (P = 0.0335) and length of time for the study (P = 0.0001). The differences in lesion intervals may have been caused by the differences in study length. Alteration in the occurrence of aphthous ulcers was demonstrated by the reduction in numbers of lesions in Study I and by the increase in length of intervals between lesions in Study III. However, a consistent pattern was not present; this indicated a lack of effect of the gel on aphthous ulcers.

Babee et al.^[12] conducted a case control study in which 40 patients with oral minor aphthous lesions were included. The duration of complete wound healing, pain score, wound size, and inflammation zone diameter in the aloe vera group were significantly lower than the placebo group (P ≤ 0.05). He concluded that aloe vera gel is effective in reducing the pain score, wound size, and the healing period. In this study, aloe vera was found to be more effective in terms of pain and burning sensation, but kenacort oral paste was superior in terms of wound healing (ulcer size). He suggested that the wound-healing properties, antiinflammatory, and immunomodulatory properties of aloe vera are the possible mechanisms in the reduction of the ulcer size.^[1]

Mansour G et al.^[11] conducted a randomized double-blinded placebo-controlled study and evaluated the clinical efficacy and the safety of newly customized natural oral mucoadhesive gels, containing either aloe vera or myrrh as active ingredients, in the management of minor recurrent aphthous stomatitis (MiRAS). He found that there was complete ulcer healing in 76.6% of patients, reduction of erythema in 86.7% of patients, and exudation in 80% of patients using aloe vera gel when compared with myrrh gel. He concluded that the aloe vera was effective in the reduction of ulcer size, erythema, and exudation compared to myrrh. This study also showed a positive response in terms of pain reduction and burning sensation in aloe vera group as compared to the kenacort group. The possible cause for the pain reduction and burning sensation is the soothing effect of aloe vera.

Aloe vera inhibits the cyclooxygenase pathway and reduces prostaglandin E2 production from arachidonic acid that contributes to its antiinflammatory properties.^[1] The healing properties of aloe vera are from a component called glucomannan, a mannose-rich polysaccharide, and gibberellin, a growth hormone, interacts with growth factor receptors on the fibroblast, thereby stimulating its activity and proliferation [Figure 7]. Other potential factor includes its immunomodulatory properties and antioxidant properties.

Figure 7: Aloe vera gel and its effect on minor aphthous ulcer

Click here to view

Based on the results, the antiinflammatory properties are more prominent than the wound healing effects of A.V. gel (measured by RAS lesion diameters). However, its effects on RAS lesions are considered curative as it decreased the pain and burning sensation.

The limitation of this study was limited sample size. More controlled clinical trials with larger sample size related to its dosage should be carried out to prove the effectiveness of the aloe vera in the treatment of oral aphthous ulcers.

Conclusion

Aloe vera has a wide spectrum of unique properties and uses. It is a promising agent in treating oral lesions in the field of oral medicine. This study indicates that aloe vera gel alleviates pain and burning sensation. However, its effectiveness is not comparable to 0.1% triamcinolone acetonide. It can be used as an alternative medicine and in patients who are allergic to steroid medication.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1.	Surjushe A, Vasani R, Saple DG. Aloe vera: A short review. Indian J Dermatol 2008;53:163-6. [PUBMED] [Full text]
2.	Bairwa R, Gupta P, Gupta VK, Srivastava B. Traditional medicinal plants: Use in Oral hygiene. IJPCS 2012;1:1529-38.
3.	Reynolds T, Dweck AC. Aloe vera gel leaf: A review update. J Ethnopharmacol 1999;68:3e37.
4.	Newall CA, Anderson LA, Phillipson JD. Herbal Medicines. A Guide for Health-Care Professionals. London: The Pharmaceutical Press; 1996.
5.	Femenia A, Sánchez ES, Simal S, Rosselló C. Compositional features of polysaccharides from aloe vera (Aloe barbadensis Miller) plant tissues. Carbohydr Polym 1999;39:109-17.
6.	Xing JM, Li FF. Purification of aloe polysaccharides by using aqueous two phase extraction with desalination. Nat Prod Res 2009;23:1424-30.
7.	Atherton P. Aloe vera: Magic or medicine. Nurs Stand 19987;12:49-52, 54.
8.	Vogler BK, Erns E. Aloe vera: A systematic review of its clinical effectiveness. Br J Gen Pract 1999;49:823-8.
9.	Garnick JJ, Singh B, Winkley G. Effectiveness of a medicament containing silicon dioxide, aloe, and allantoin on aphthous stomatitis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1998;86:550-6.
10.	Bhalang K, Thunyakitpisal P, Rungsirisatean N. Acemannan, a polysaccharide extracted from aloe vera is effective in the treatment of oral Apthous Ulceration. J Altern Complement Med 2013;19:229-34.
11.	Mansour G, Ouda S, Shaker A, Abdallah HM. Clinical efficacy of new aloe vera- and myrrh-based oral mucoadhesive gels in the management of minor recurrent aphthous stomatitis: A randomized, double-blind, vehicle-controlled study. J Oral Pathol Med 2014;43:405-9.
12.	Babaee N, Zabihi E, Mohseni S, Moghadamnia AA. Evaluation of the therapeutic effects of aloe vera gel on minor recurrent aphthous stomatitis. Dent Res J 2012;9:381-5.
13.	Choonhakarn C, Busaracome P, Sripanikulchai B, Sarakarn P. The efficacy of aloe vera gel in the treatment of oral lichen planus: A randomized controlled trial. Br J Dermatol 2008;158:573-7.
14.	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.
15.	Amanat D, Bahri NR, Tazaesh L. Effect of Aloe vera versus local triamcinolone in treatment of oral lichen planus. Shiraz Univ Dent J 2011;12:206-13.
16.	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;342:447-50.
17.	Reddy RL, Reddy RS, Ramesh T, Singh TR, Swapna LA, Laxmi NV. Randomized trial of aloe vera gel versus triamcinolone acetonide ointment in the treatment of oral lichen planus. Quintessence Int 2012;43:793-800.
18.	Sudarshan R, Annigeri RG, Sree Vijayabala G. Aloe vera in the treatment for oral submucous fibrosis-a preliminary study. J Oral Pathol Med 2012;41:755-61.
19.	Alam S, Ali I, Giri KY, Gokkulakrishnan S, Natu SS, Faisal M, et al. Efficacy of aloe vera gel as an adjuvant treatment of oral submucous fibrosis. Oral Surg Oral Med Oral Pathol Oral Radiol 2013;117:717-24.
20.	Su CK, Mehta V, Ravi Kumar L, Shah R, Pinto H, Halpern J, et al. Phase II double-blind randomized study comparing oral Aloe vera versus placebo to prevent radiation-related mucositis in patients with head-and-neck neoplasms. Int J Radiat Oncol Biol Phys 2004;60:171-7.
21.	Jornet PL, Camacho – Alonso F, Molino-Pagan D. Prospective, randomized, double blind, clinical evaluation of aloe vera barbadensis, applied in combination with a tongue protector to treat burning mouth syndrome. J Oral Pathol Med 2013;42:295-301.
22.	Shetty PJ, Hegde V, Gomes L. Anti-candidal efficacy of denture cleansing tablet, triphala, aloe vera, and cashew leaf on complete dentures of institutionalized elderly. J Ayurveda Integr Med 2014;5:11-4. [PUBMED] [Full text]
23.	Morales-Bozo I, Rojas G, Ortega-Pinto A, Espinoza I, Soto L, Plaza A, et al. Evaluation of the efficacy of two mouth rinses formulated for the relief of xerostomia of diverse origin in adult subjects. Gerodontology 2012;29:e1103-12.
24.	Bhat G, Kudva P, Dodwad V. Aloe vera: Nature's soothing healer to periodontal disease. J Indian Soc Periodontol 2011;15:205-9. [PUBMED] [Full text]
25.	Jawaid M, Panat SR, Aggarwal A, Upadhayay N, Aggarwal N, Durgvanshi A, et al. Aloe vera in oral diseases: Move toward the Nature. J Dent Sci Oral Rehab 2016;7:67-73.
26.	Ship JA. Recurrent aphthous stomatitis. An update. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1996:81:141-7.