Vol. 116 No.

6 December 2013

Efcacy of aloe vera gel as an adjuvant treatment of oral

submucous brosis
Sarwar Alam, MDS,a Iqbal Ali, MDS,b K.Y. Giri, MDS,c S. Gokkulakrishnan, MDS,d Subodh S. Natu, MDS,e
Mohammad Faisal, MDS,f Anshita Agarwal, MDS,g and Himanshu Sharma, MDSa
Institute of Dental Sciences, Bareilly, Uttar Pradesh; Career Post Graduate Institute of Dental Sciences and Hospital, Lucknow, Uttar Pradesh; Jamia
Millia Islamia, New Delhi; Vananchal Dental College and Hospital, Garhwa, Jharkhand, India

Objective. Definitive therapy is not defined for the management of oral submucous fibrosis (OSMF). This study evaluated the
efficacy of aloe vera gel as an adjuvant treatment of OSMF.
Study Design. A double-blind, placebo-controlled, parallel-group randomized controlled trial was conducted on 60 subjects
with OSMF divided into medicinal treatment (submucosal injection of hyaluronidase and dexamethasone, n 30) and
surgical treatment (n 30) categories. Each category was randomly divided into groups A (with aloe vera, n 15 per category)
and B (without aloe vera, n 15 per category). Follow-up assessment for various symptoms was performed, and results were
analyzed using paired and unpaired Student t tests.
Results. The group receiving aloe vera had a significant improvement in most symptoms of OSMF (P < .01) compared with the
nonealoe vera group, in both the medicinal and surgical categories.
Conclusions. Aloe vera gel was effective as an adjuvant in treatment of OSMF. (Oral Surg Oral Med Oral Pathol Oral Radiol
2013;116:717-724)

Oral submucous brosis (OSMF) is a chronic, progres-
sive, debilitating disease of the oral mucosa involving the
oropharynx and rarely the larynx.1 The disease is char-
acterized by blanching and stiffness of the oral mucosa,
trismus, a burning sensation in the mouth, and hypo-
mobility of the soft palate and tongue with loss of
gustatory sensation. It is associated with juxtaepithelial
inammatory reaction followed by a broelastic change
of the lamina propria and epithelial atrophy leading to
stiffness of the oral mucosa, causing trismus and inability
to eat.2 This disease is generally noted in South Asian
populations or among those who have emigrated from
South Asia. Other geographic clustering may be noted
in Burma (Myanmar), with sporadic cases observed
in southern Vietnam, Thailand, China, and Nepal.2 The
prevalence of OSMF in random samples of the
a
Senior Lecturer, Department of Oral and Maxillofacial Surgery,
Institute of Dental Sciences, Bareilly, Uttar Pradesh.
b involve juxtaepithelial inammatory reaction and brosis
Professor and Head, Department of Oral and Maxillofacial Surgery,
Career Post Graduate Institute of Dental Sciences and Hospital,
Lucknow, Uttar Pradesh.
c
Professor, Department of Oral and Maxillofacial Surgery, Institute of
Dental Sciences, Bareilly, Uttar Pradesh.
d
Professor and Head, Department of Oral and Maxillofacial Surgery,
Institute of Dental Sciences, Bareilly, Uttar Pradesh.
e
Senior Lecturer, Department of Oral and Maxillofacial Surgery,
Career Post Graduate Institute of Dental Sciences and Hospital,
Lucknow, Uttar Pradesh.
f
Associate Professor, Department of Oral and Maxillofacial Surgery,
Faculty of Dentistry, Jamia Millia Islamia, New Delhi.
g
Senior Lecturer, Department of Oral Pathology, Vananchal Dental
College and Hospital, Garhwa, Jharkhand.
Received for publication Apr 10, 2013; returned for revision Aug 1,
2013; accepted for publication Aug 5, 2013.
2013 Elsevier Inc. All rights reserved.
2212-4403/$ - see front matter
http://dx.doi.org/10.1016/j.oooo.2013.08.003
population in India is up to 0.4%. This indicates that
there may be millions of persons with OSMF. This
disease is increasing rapidly in India, corresponding to
the current upsurge in the popularity of various manu-
factured areca nut preparations, such as mawa and pan
masala.
The prevalence of OSMF is found to be 6.42 per
1000, and the male-to-female ratio, 4.9:1. Signicantly
younger persons (age <30 years) are increasingly
affected by this disease.3 OSMF commonly involves
the soft palate (91.4%), buccal mucosa (72.4%), retro-
molar region (70.7%), and tongue (8.6%),4 and the
condition is considered precancerous.5 Malignant
transformation of OSMF has been reported to be from
2.3% to 7.6%.3,6
The established etiologic factors are areca nut,7
chilies,8 vitamin B deciencies, and genetic and immu-
nologic predisposition.7,9 The pathogenesis is believed to
in the oral mucosa, probably owing to increased cross-
linking of collagen through upregulation of lysyl oxidase
activity. Fibrosis, or the buildup of collagen, results
from the effects of areca nut, which increase collagen
production (e.g., stimulated by arecoline, an alkaloid)
and decrease collagen degradation. Thus, OSMF is now
considered a collagen metabolic disorder.
Statement of Clinical Relevance
Aloe vera gel was effective as an adjuvant in the
treatment of oral submucous brosis, a premalignant
condition prevalent in South Asia.

717
ORAL MEDICINE
718 Alam et al.
Clinical management of OSMF continues to be
unsatisfactory. Signs and symptoms persist and progress
despite attempted treatments. Several categories of drugs
are used to treat debilitating brosis. However, the effect
is not satisfactory. No single drug has effectively reversed
the initiation and development of OSMF, for multiple
reasons, such as the progressive nature of the disease, the
lack of complete knowledge of the pathogenesis of the
disease, and the limited routes of administration. It is
important to investigate the means of controlling this
chronic progressive and symptomatic illness, considering
its troublesome symptoms, precancerous nature, and
prevalence in a vast geographic region.
An attempt has been made to study the effect of
topical aloe vera gel as an adjuvant to the treatment.
Although satisfactory treatment is not yet recognized, 2
treatment options have been used with some benet.
The purpose of this study was to determine the efcacy
of aloe vera gel as an adjuvant to the following treat-
ment options in the management of OSMF.
i. Submucosal local injection of (Hyalase hyaluroni-
dase 1500 IU; Wockhardt UK, Wrexham, UK)
diluted with 1 mL of 2% lignocaine (with 1:80000
adrenaline) twice a week for the rst 3 weeks; fol-
lowed by submucosal local injection of hyaluronidase
diluted with 4 mg dexamethasone and 1 mL of 2%
lignocaine (with 1:80000 adrenaline) twice a week
for the next 7 weeks.
ii. Surgical excision of brotic bands, with or without
graft.
MATERIALS AND METHODS
Study settings and cases
A double-blind, placebo-controlled, parallel-group ran-
domized controlled trial was carried out to evaluate the
efcacy of aloe vera gel as an adjuvant to the medicinal
and surgical treatment of OSMF among 60 patients
diagnosed with the disease. The patients were selected,
irrespective of age, sex, religion, and socioeconomic
status, from all those attending the outpatient Department
of Oral and Maxillofacial Surgery at Career Post Grad-
uate Institute of Dental Sciences and Hospital, Lucknow,
Uttar Pradesh, India. Patients with uncontrolled diabetes,
compromised immunity, and chronic infection were
excluded from this study. Routine blood and urine
investigations were done, and radiographs were taken, to
exclude any associated diseases or pathology.
The study protocol was reviewed and approved by
the Institutional Ethical Committee. The treatment
plan was explained to all the study participants, and
their consent was obtained. Patients were graded
according to the classication given by Khanna and
Andrade.10 Thirty patients with grade I and grade II
OSMF were planned for medicinal treatment, and 30
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December 2013
patients with grade III and grade IV OSMF were
planned for surgical treatment.
Management
Patients were actively discouraged from consuming the
identied etiologic factors, such as pan masala, gutkha,
betel quid, tobacco, and other chronic irritants such as
hot and spicy food. Patients with anemia were treated
and encouraged to eat a well-balanced diet. All patients
underwent biopsy to conrm the diagnosis and also to
correlate the clinical and histopathologic ndings. Inci-
sional biopsies were taken from the retromolar and
buccal mucosal regions. Additional biopsies were taken
from areas that showed clinical alterations in the mucosa
suggestive of atypia or malignant transformation.
All patients were put on a supplementary therapeutic
regimen of Lycostar (lycopene, 5000 mg; carotene,
10.33 mg; rened wheat germ oil, 25 mg; zinc sulfate,
27.45 mg; and selenium dioxide, 75 mg; Mankind
Pharma Ltd., New Delhi, India) twice daily and
Capsule Becosules-Z (Pzer Ltd., USA. thiamine, 10
mg; riboavin, 10 mg; pyridoxine, 3 mg; vitamin B12,
15 mg; niacinamide, 100 mg; calcium pantothenate, 50
mg; folic acid, 1.5 mg; biotin, 100 mg; ascorbic acid, 50
mg; and zinc sulfate, 41.4 mg, equivalent to 15 mg of
elemental zinc) once daily during the treatment and up
to 6 months after the completion of treatment. They
were advised to perform physiotherapy for mouth
opening 4 to 5 times a day on a regular basis.
Impacted or malposed third molars having possible
correlation with the prognosis of OSMF treatment were
removed. All possible foci of infections were eradi-
cated. Correction of local irritants, such as a sharp
tooth, was performed. Fractured and carious teeth were
restored. Oral prophylaxis was provided. Patients were
assessed after 2 weeks; and after they gave assurance
that they had suspended the habit as instructed, further
management was continued.
Medicinal treatment. Patients planned for medici-
nal treatment were given submucosal injections twice
a week of hyaluronidase (1500 IU) diluted with 1 mL of
2% lignocaine (with 1:80000 adrenaline) for the rst 3
weeks. This was followed by submucosal injection
twice a week of hyaluronidase (1500 IU) diluted in
4 mg dexamethasone and 1 mL of 2% lignocaine (with
1:80000 adrenaline) for the next 7 weeks. The entire
content of the syringe was injected using a 26-gauge
needle, with not more than 0.2 mL of solution per site.
Massaging the cheek with the mouth closed, followed
by physiotherapy with a Heister mouth gag for 20
minutes, was done after the submucosal injection.
Surgical treatment. Under local or general anesthesia
as required in the individual case, the brous bands in
the buccal mucosa were palpated and incised along the
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Volume 116, Number 6
occlusal line, starting from the angle of the mouth
extending posteriorly up to the retromolar region, bilat-
erally, to the depth of connective tissue. A Heister mouth
gag was then applied to achieve a maximal interincisal
opening of 35 mm, and coronoidectomy was done where
required to get the maximal possible opening.
Suitable graft (buccal fat pad, nasolabial ap, or
collagen membrane) was then placed over the mucosal
defect. Patients were placed on physiotherapy with
a wooden spatula from the fth postoperative day, at
least 4 to 5 times a day, for a minimum of 6 months.
Each treatment category (medicinal and surgical) was
randomly divided into 2 groups, A and B, having an
equal number of patients. Group A patients were advised
to apply aloe vera gel over the buccal mucosa, palate,
retromolar region, and oor of the mouth twice daily
during the treatment as well as in the follow-up phase, up
to 6 months after the completion of medicinal or surgical
treatment, whereas no such advice was given to group B
patients (Figure 1). The 4 subgroups were labeled group
A med, group A surg, group B med, and group B surg.
Outcome assessment
The follow-up assessment of subjects was done on
a twice-a-week basis, whereas data were recorded on
a weekly basis during the medicinal treatment and
monthly after the completion of the treatment, up to 6
months. Neither local nor systemic side effects were
noted in the groups. In surgically treated patients,
postoperative follow-up was performed monthly up to 6
months. The criteria for assessment were as follows: the
burning sensation of the mouth was measured on
a linear scale reading from 0 to 10, taking 5 as the
default initial reading and benchmark; mouth opening
was measured (in millimeters) from the incisal-most
point of the labial surface of the upper central incisor to
the incisal-most point of the labial surface of the lower
central incisor or (for partially edentulous participants)
in between the anterior-most teeth present in both
arches; tongue protrusion was measured (in millime-
ters) from the incisal-most point of the labial surface of
the upper incisor to the tip of the dorsal surface of the
tongue on maximal protrusion or (for partially edentu-
lous participants) from the anterior-most teeth present
to the tip of the dorsal surface of the tongue on maximal
protrusion. Suppleness and elasticity of the buccal
mucosa were assessed based on the distance (in centi-
meters) between the tips of the ear lobes on maximal
cheek blowing.
Statistical analysis
Data obtained were analyzed with SPSS software
(version 15; SPSS Inc, Chicago, IL, USA). The ndings
of various parameters were evaluated and analyzed
ORIGINAL ARTICLE
Alam et al. 719
statistically using paired and unpaired Student t tests.
Comparisons between group A and group B were done
separately for medicinally and surgically treated
patients. A P value of .05 was considered statistically
signicant.
RESULTS
A total of 60 participants (53 men and 7 women) were
included in the study. The majority, 41 (68.3%), were
21 to 40 years of age. Male predominance was found in
both groups; in group A (n 30), 26 were men and 4
were women (6.5:1); in group B (n 30), 27 were men
and 3 were women (9:1).
Figure 2 shows that there was a signicant decrease
(P < .01) in the mouth burning sensation for the
medicinal treatment in group A (group A med) from the
beginning of the treatment (5.0  0 on the rating scale)
to the completion of the medicinal therapy (tenth week;
0.38  0.47), with further reduction at the end of the
sixth month (0.26  0.40). In group B med, during the
treatment time, patients had a continuous decrease in
burning sensation, 2.23  1.14, but after completion of
treatment there was relapse in reduction of burning
sensation to 2.96  1.96 until the sixth month. A
considerable decrease in burning sensation was noticed
after week 2 of treatment in group A med (1.73  1.01)
compared with group B med (3.53  1.17) against the
initial benchmark reading of 5  0.
In the surgically treated patients, a signicant
decrease in the burning sensation was observed in
group A surg (5  0 to 3.66  0.97; P < .01) but not in
group B surg (5  0 to 4.03  0.93) 1 month after
surgery. The burning sensation increased (4.03  0.95
to 4.23  0.75) in group B surg from the rst month to
the sixth month postoperatively, whereas there was
a gradual and continuous decrease in burning sensation
in group A surg during the same observation period
(see Figure 2).
At baseline, the pretreatment mean mouth opening
in medicinally treated patients (Figure 3) was 23.46 
5.37 mm and 24.0  7.53 mm in group A med and
group B med, respectively (P > .05). Mouth opening
increased in group A med by 13.74 mm from initiation
to the 6-month follow-up, an amount more than twice
that found in group B med (6 mm) (P < .01). After the
tenth week, further increases were not noted. In fact,
after the completion of the medicinal therapy, there
was decrease in mouth opening in group B med (from
32.40  6.96 mm to 30.0  7.41 mm) over months 2
through 6, whereas group A med remained essentially
stable.
In the surgically treated patients, the postoperative
mean mouth opening after the rst month was 37.46 
2.50 mm in group A (group A surg) and 37.33  2.12
mm in group B (group B surg; P > .05). In group A
ORAL MEDICINE
720 Alam et al.
Fig. 1. Flow chart of the inclusion of subjects.
Fig. 2. Comparison of the burning sensation of the mouth between group A and group B in patients treated medicinally and
surgically.
surg, there was an insignicant increase in mouth
opening (37.46  2.50 mm to 38.93  3.32 mm) from
the rst month after surgery to the 6-month follow-up
(P > .05), whereas in group B surg, there was
considerable decrease (37.33  2.12 mm to 34.0  3.18
mm) in mouth opening during the same period (see
Figure 3).
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December 2013
Tongue protrusion (Figure 4) increased in group A
med from 26.00  5.83 mm to 32.13  6.83 mm,
although the amount was not signicantly greater
than the increase in group B med (32.46  6.35 mm to
38.33  5.05 mm) from the initiation to the completion
of the injectable therapy, that is, by the tenth week.
After completion of medicinal treatment and until the
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Fig. 3. Comparison of mouth opening between group A and group B in patients treated medicinally and surgically.
Fig. 4. Comparison of tongue protrusion between group A and group B in patients treated medicinally and surgically.
6-month follow-up, a decrease was found in group B
med (38.33  5.05 mm to 36.66  5.31 mm),
compared with the slight decrease (32.13  6.83 mm to
31.67  6.66 mm) in group A med.
Among surgically treated patients, the rst months
postoperative mean tongue protrusion was 22.86 
5.08 mm in group A surg and 24.2  5.83 mm in group
B surg (P > .05). There was an insignicant increase
(22.86  5.08 mm to 23.13  5.59 mm) in tongue
protrusion from the rst month after the surgery to the
sixth month in both surgical groups (see Figure 4).
Also, ear lobe distances on cheek blowing in group A
med (27.36  2.32 cm to 28.73  2.58 cm) and group
B med (26.93  1.89 cm to 27.53  2.22 cm) after the
completion of medicinal treatment were similar. There
was a considerable increase (Figure 5) in ear lobe
distance in group A med from initiation to the third
week (27.36  2.32 cm to 27.80  2.44 cm) and from
the sixth week to the eighth week (28.07  2.52 cm to
ORIGINAL ARTICLE
Alam et al. 721
28.52  2.56 cm) compared with group B med (from
26.93  1.89 cm to 27.03  1.91 cm in the rst 3
weeks and from 27.33  2.10 cm to 27.50  2.19 cm in
the sixth to eighth weeks). Among surgically treated
patients, the results obtained with the mean ear lobe
distance were insignicantly different from 1 month to
6 months after surgery between group A surg (26.53 
2.2 cm to 27.10  2.46 cm) and group B surg (27.96 
2.72 cm to 27.53  2.81 cm) (see Figure 5).
DISCUSSION
To date, there has been no ideal treatment available for
OSMF. Discontinuation of the habit is the rst and
foremost step before treatment planning. The treatment
employed in this study was rst suggested by Khanna
and Andrade.10 According to them, patients with an
early stage of OSMF should be treated medicinally,
whereas patients with an advanced stage of OSMF
should be treated surgically. Aloe vera is an emollient
ORAL MEDICINE
722 Alam et al.
Fig. 5. Comparison of ear lobe distance on cheek blowing between group A and group B in patients treated medicinally and
surgically.
resin and a mannoprotein containing many amino acids
that have been called wound-healing hormones. The
polysaccharides in the gel of the leaves have wound-
healing, anti-inammatory, anticancer, immunomodu-
latory, and gastroprotective properties.11
The medicinal treatment used in our study was sug-
gested in 1985 by Kakar et al.,12 who studied different
combinations and regimens and recommended that
patients should be given a course of local injection of
hyaluronidase twice a week for the rst 3 weeks, fol-
lowed by a combination of dexamethasone and hyal-
uronidase locally for the next 7 weeks, to achieve
quicker and maximal improvement. Massaging of the
cheek with the mouth closed and physiotherapy with
a Heister mouth gag for 20 minutes were done after the
submucosal injection, as Borle and Borle1 found that
the mechanical insults due to insertion of injection
needles and chemical irritation of injected uids after
a certain time aggravate brosis, trismus, dysphagia,
and other morbidity, owing to the progressive nature of
the disease.1
The ndings in group B med for the burning
sensation of the mouth are similar to the ndings
of Katharia et al.,13 who used injection of placental
extract (Placentrex, Albert David Ltd, Kolkata, West
Bengal, India) for 1 month in 22 patients and found
a 40.21% reduction in burning sensation, whereas in
our group A med the reduction was as high as 92.4%.
The ndings of this study clearly indicate that the use
of aloe vera gel along with medicinal treatment results
in a remarkable improvement in the burning sensation.
In group A med, there was a constant decrease in the
burning sensation, even after the completion of treat-
ment and up to the 6-month follow-up (from 0.38
to 0.26), whereas there was a relapse in reduction
of burning sensation (2.23 to 2.96) in group B med. This
nding indicates that aloe vera gel, along with supple-
mentary therapeutic drugs and vitamins, continues to
reduce the burning sensation even after the completion
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December 2013
of medicinal therapy, whereas there is relapse without
aloe vera gel application.
The ndings for mouth opening in group B med (i.e.,
improvement of 35%) are similar to the ndings of
Katharia et al.,13 in which a 28.26% improvement with
the treatment with Placentrex was found. Haque et al.14
studied the effect of interferon-g and found a 42%
gain in net mouth opening after treatment. The mouth
opening improvement found by Lin and Lin15 was 64%
to 82% after 6 weeks of treatment with collagenase
injection. This result is similar to our nding in group
A med, in which the improvement was 60.5%, which
is signicantly higher than the improvement in group
B med. Thus, aloe vera gel used in combination with
hyaluronidase and dexamethasone, along with a sup-
plementary therapeutic regimen, was found effective
for improvement in mouth opening. Also, the mouth
opening achieved after the completion of medicinal
treatment is maintained in the follow-up period in group
A med (aloe vera), whereas relapse was observed in
group B med (no aloe vera).
The groups with aloe vera gel application and
without aloe vera gel application showed insignicant
difference in improvement in tongue protrusion and
had improvement levels similar to the 18.5% found
after 1 month of treatment with Placentrex by Katharia
et al.13 and to the 26.3% found after antioxidant therapy
in a study by Gupta et al.16 We found that tongue
protrusion measures increased by 8.69% (26.0 to 28.26
mm) in group A med in the rst 2 weeks of treatment,
compared with 2.68% (32.46 to 33.33 mm) in group B
med, without further gains after completion of medic-
inal treatment. These results indicate that topical aloe
vera gel may contribute to quicker improvement of
tongue protrusion and maintaining tongue protrusion
achieved after the completion of medicinal treatment.
Here it is important to mention that the restriction of
tongue mobility is not only because of the brosis of
the tongue but also because of the involvement of the
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Volume 116, Number 6
retromolar area and the oor of the mouth. The afore-
mentioned result can be attributed to an increase in the
laxity of the retromolar area and the oor of the mouth
after the treatment.
For mean ear lobe distance, which is indicative
of suppleness and elasticity of the buccal mucosa and
was measured with cheek blowing in the group treated
medicinally, no signicant difference was found bet-
ween the groups from the initiation to the completion
of standard medicinal treatment. Kakar et al.12 found
improvement in the suppleness of the oral tissue in
66.7%, 83.7%, 91.7%, and 70.8% of patients treated
with dexamethasone, hyaluronidase, a combination of
hyaluronidase and dexamethasone, and Placentrex,
respectively, for 10 weeks. Our study found a consid-
erable increase of 1.6% (27.36 to 27.8 cm) in the ear
lobe distance within the rst 3 weeks of treatment in
group A med, compared with only 0.37% (26.93 to
27.03 cm) in group B med, which indicates the positive
role of aloe vera gel in quicker improvement in the
suppleness and elasticity of the buccal mucosa in the
initial phase of the medicinal treatment.
Surgically treated patients
In our studys surgically treated patients, we found
that all of the grafts were well accepted. Complica-
tions such as ap loss, ap avulsion, and wound
dehiscence were not encountered. Incidence of infec-
tion or necrosis of the graft was not found, although
the patients applying aloe vera gel had quicker heal-
ing, better acceptance, and healthier appearance of the
graft mucosa.
In this study, a signicant decrease of 26.8% (5.0
to 3.66) in burning sensation of the mouth in group A
surg from before the surgery to 1 month after the
surgery, compared with 19.4% (5.0 to 4.03) in group B
surg, was found, which suggests a positive role of aloe
vera gel in the reduction of the burning sensation from
the time of surgery and during the rst postoperative
month. The reduction in burning sensation after the
surgery to improve the mouth opening is possibly
because of the removal of the mucosa responsible
for the burning sensation and the replacement with
healthier and disease-free graft mucosa, along with
the effect of aloe vera gel application. In a study by
Borle et al.,17 41 out of 47 patients reported reduction
in the burning sensation after the surgery without any
supplementary medicinal treatment, although there
were no data available on the percentage of reduc-
tion in burning sensation. There was a considerable
reduction of 47.26% (3.66 to 1.93) in the burning
sensation in our group A surg from the rst month
after surgery to the 6-month follow-up, compared with
a slight relapse of 6.69% (4.03 to 4.30) in group B
ORIGINAL ARTICLE
Alam et al. 723
surg, which is similar to that with Placentrex injection
(40.21%) found by Katharia et al.,13 suggesting the
benets of aloe vera gel application along with the
supplementary therapeutic drugs and vitamins advised
in our study.
The mouth opening of 37.46  2.50 mm in group A
surg and 37.33  2.12 mm in group B surg was
maintained 1 month after the surgery. After 6 months
of follow-up, there was an increase of 3.77% (37.46 to
38.93 mm) in mouth opening in group A surg, whereas
there was a considerable decrease of 8.92% (37.33 to
34.0 mm) in mouth opening in group B surg. Findings
from Borle et al.17 found no relapse in mouth opening
2 years after surgery in which they used an extended
nasolabial graft followed by physiotherapy without
any supplementary therapeutic regimen. In contrast,
Mehrotra et al.2 found 0.7% to 1.8% relapse in mouth
opening during the months after surgery with buccal
fat pad, tongue ap, nasolabial ap, and skin grafting,
which was similar to our nding of relapse in the
group without aloe vera gel application. Yeh18 used
buccal fat pad for reconstruction of buccal mucosa
after surgery to release brotic bands and found 10.2%
of relapse in the mouth opening achieved after surgery
after the follow-up period of 10 to 38 months. In the
study by Khanna and Andrade,10 in which they used
a palatal island ap, a mean relapse of 12.22% was
found over a period of 4 years postoperatively; and Lai
et al.19 found a 23% decrease in mouth opening in
50% of their patients with split-thickness skin graft,
in 62% of the patients with fresh amnion graft, and in
32% of the patients with buccal fat pad graft, after 2
years of follow-up. The observation in the aloe vera
group of slight increase in mouth opening indicates
its importance in the prevention of relapse of the
improved mouth opening achieved after surgery. The
relapse in the mouth opening achieved after surgery
without the application of aloe vera gel is believed to
be because of the graft contracture during healing and
the recurrence of brosis.
In conclusion, our ndings indicate that the aloe vera
gel was benecial as an adjunct to medicinal and
surgical approaches in the treatment of OSMF. Further
study with longer follow-up periods and larger sample
sizes is required to assess the role of aloe vera gel as
a mainstream therapeutic regimen.
REFERENCES
1. Borle RM, Borle SR. Management of oral submucous brosis:
a conservative approach. J Oral Maxillofac Surg. 1991;49:
788-791.
2. Mehrotra D, Pradhan R, Gupta S. Retrospective comparison of
surgical treatment modalities in 100 patients with oral submucous
brosis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod.
2009;107:e1-e10.
ORAL MEDICINE
724 Alam et al.
3. Hazarey VK, Erlewad DM, Mundhe KA, Ughade SN. Oral sub-
mucous brosis: study of 1000 cases from central India. J Oral
Pathol Med. 2007;36:12-17.
4. Afroz N, Hasan SA, Naseem S. Oral submucous brosis: a dis-
tressing disease with malignant potential. Indian J Community
Med. 2006;31:270-271.
5. Paymaster JC. Cancer of the buccal mucosa: clinical study of 650
cases in Indian patients. Cancer. 1956;9:431-435.
6. Murti PR, Bhonsle RB, Pindborg JJ, Daftary DK, Gupta PC,
Mehta FS. Malignant transformation rate in oral submucous
brosis over a 17-year period. Community Dent Oral Epidemiol.
1985;13:340-341.
7. Tilakaratne WM, Klinikowski MF, Saku T, Peters TJ,
Warnakulasuriya S. Oral submucous brosis: review on aetiology
and pathogenesis. Oral Oncol. 2006;42:561-568.
8. Sirsat SM, Khanolkar VR. Submucous brosis of the palate in
diet preconditioned Wistar rats: induction by local painting of
capsaicindan optical and electron microscopic study. Arch
Pathol. 1960;70:171-179.
9. Rajendran R, Vidyarani. Familial occurrence of oral submucous
brosis: report of eight families from northern Kerala, south India.
Indian J Dent Res. 2004;15:139-144.
10. Khanna JN, Andrade NN. Oral submucous brosis: a new
concept in surgical management: report of 100 cases. Int J Oral
Maxillofac Surg. 1995;24:433-439.
11. Fresh Organic Aloe Vera. Available at: http://www.bevital.co.uk/
acatalog/Aloe_Vera-The_wand_of_heaven.html. Accessed January
10, 2013.
12. Kakar PK, Puri RK, Venkatachalam VP. Oral submucous
brosisdtreatment with hyalase. J Laryngol Otol. 1985;99:
57-59.
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December 2013
13. Katharia SK, Singh SP, Kulshreshtha VK. The effects of placenta
extract in management of oral submucous brosis. Indian J
Pharmacol. 1992;24:181-183.
14. Haque MF, Meghji S, Nazir R, Harris M. Interferon gamma (IFN-
gamma) may reverse oral submucous brosis. J Oral Pathol Med.
2001;30:12-21.
15. Lin HJ, Lin JC. Treatment of oral submucous brosis by colla-
genase: effects on oral opening and eating function. Oral Dis.
2007;13:407-413.
16. Gupta S, Reddy MV, Harinath BC. Role of oxidative stress and
antioxidants in aetiopathogenesis and management of oral sub-
mucous brosis. Indian J Clin Biochem. 2004;19:138-141.
17. Borle RM, Nimankar PV, Rajan R. Extended nasolabial aps in
the management of OSMF. Br J Oral Maxillofac Surg. 2009;47:
382-385.
18. Yeh CJ. Application of the buccal fat pad to the surgical treatment
of oral submucous brosis. Int J Oral Maxillofac Surg. 1996;25:
130-133.
19. Lai DR, Chen HR, Lin LM, Huang YL, Tsai CC. Clinical eval-
uation of different treatment methods for oral submucous brosis:
a 10-year experience with 150 cases. J Oral Pathol Med. 1995;24:
402-406.
Reprint requests:
Sarwar Alam
19, Staff Residence, Institute of Dental Sciences
Bareilly-243006, Uttar Pradesh
India
sarwaralam@rediffmail.com