ORIGINAL RESEARCH Topical Curcumin and Triamcinolone Acetonide in Recurrent Minor Aphthous Ulcers: A Pilot Trial Praveena Raman1, Raghuram Pitty2, Chandrasekar Lakshmi Krithika3, SP Nehru Anand4, Gayathri Ponnusami Subramani5 ABSTRACT Aim: To evaluate the efficacy of topical curcumin and topical triamcinolone acetonide in a professional population with minor aphthous ulcers by assessing six clinical variables: site, size, pain, healing period, frequency of recurrence and number of ulcers. Materials and methods: This randomized, parallel designed pilot trial was performed on 60 symptomatic individuals with minor aphthous ulcer. Willing participants were allocated randomly into group I and group II. Participants in group I were treated with topical curcumin and group II were treated with topical triamcinolone acetonide for a period of 6 months. All participants were blinded to the drug they received. Participants were assessed on day 1, day 3, day 5, day 7, and after healing for symptomatic reduction in pain, size, healing period, frequency of recurrence, and in the number of ulcers. Statistically, independent sample t test, Chi-square test, and Log rank Kaplan–Meier survival analysis were performed. Results: Lower labial mucosa was found to be the predominant site of minor aphthous ulcer in both the groups. A gradual reduction in pain and size was noted in both the groups with statistical significance of p value <0.001. All the ulcers in both the groups healed completely without scarring within 2 weeks with statistical significance. In both the treatment groups, new ulcers occurred throughout the follow-up period of 6 months. The mean number of the ulcers are statistically not significant with p value >0.05. Conclusion: Our study showed clinically beneficial effects with topical curcumin with regard to ulcer size, pain, healing, and recurrence rate. Also topical curcumin gel was well tolerated and performed ot par with topical triamcinolone acetonide oral paste with a borderline favorable result with triamcinolone. Clinical relevance: Curcumin can be safely recommended on a long-term basis as a more appealing therapeutic agent and is a better alternative choice for aphthous ulcers in children, pregnant woman, lactating mother, and in immunocompromised individuals. Keywords: Alternative treatment, Aphthous ulcers, Curcumin, Recurrent aphthous stomatitis, Topical steroid, Triamcinolone acetonide, Turmeric, Ulcer healing, Ulcer pain. The Journal of Contemporary Dental Practice (2020): 10.5005/jp-journals-10024-2901 INTRODUCTION 1Department of Oral Medicine and Radiology, Sathyabama Dental Recurrent aphthous stomatitis (RAS, aphthae; canker sores) College and Hospital, Chennai, Tamil Nadu, India is the most common ulcerative condition of the oral mucosa 2,3Department of Oral Medicine and Radiology, SRM Dental College, characterized by multiple, recurrent, small, round, or ovoid ulcers Ramapuram, Chennai, Tamil Nadu, India with circumscribed margins, erythematous haloes, and yellow or 4Span Dental Care Centre, Mylapore, Chennai, Tamil Nadu, India gray floors that present first in childhood or adolescence and heals 5 1,2 Department of Oral Medicine and Radiology, Thai Moogambigai spontaneously with subsequent recurrence. The individual ulcers Dental College, Chennai, Tamil Nadu, India may occur in any form: minor, major, and herpetiform aphthae, Corresponding Author: Praveena Raman, Department of Oral with minor type being the most common one.1,2 In about 80% of Medicine and Radiology, Sathyabama Dental College and Hospital, participants with minor aphthous, the condition develops before Chennai, Tamil Nadu, India, Phone: +91 7373230303, e-mail: the age of 30. A higher prevalence has been found in the higher [email protected] socioeconomic groups, in females, and among individuals with 3–5 How to cite this article: Raman P, Pitty R, Krithika CL, et al. Topical stress, such as students at the time of examinations. Due to the Curcumin and Triamcinolone Acetonide in Recurrent Minor indeterminate etiology of the disease, it is difficult to find a definitive Aphthous Ulcers: A Pilot Trial. J Contemp Dent Pract 2020;21(8): cure, and current treatments are aimed toward ameliorating the 884–890. symptoms. There are very limited published clinical evidence for Source of support: Nil the efficacy of the therapies used in this condition. The American Conflict of interest: None Academy of Oral Medicine recommends topical treatment for aphthous ulcers. Topical corticosteroids have remained the mainstay of therapy for RAS.3 “Curcumin” (diferuloylmethane) is the principal curcuminoid of 6 (IL-6), tumor necrosis factor (TNF), and various other chemokines the popular Indian spice “Turmeric,” which is a member of the ginger that could suppress inflammation through multiple pathways.6,7 It family. The curcuminoids are the polyphenols and are responsible is used in various systemic conditions and has also been tried in for the yellow color of turmeric, first identified in 1910 by Lampe oral mucosal conditions such as oral submucous fibrosis (OSMF), and Milobedzka. It is a common spice known mostly for its use in oral lichen planus (LP), and oral precancers.8 Besides its varied Indian dishes as a common ingredient in curries and other ethnic beneficial and safer effects in humans, curcumin has not been meals. Curcumin is as powerful as an antioxidant. Studies show extensively investigated in the management of aphthous ulcers. that curcumin could downregulate the expression of interleukin Instead of using a topical anesthetic or an anti-inflammatory agent, © The Author(s). 2020 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (https://creativecommons. org/licenses/by-nc/4.0/), which permits unrestricted use, distribution, and non-commercial reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Spice Substituting Steroid a completely safer and a naturally occurring agent can be used as Based on Figure 1, participants under any other form an alternative for the symptomatic relief of aphthous ulcers. of treatment for their oral ulcers, those under orthodontic Corticosteroids have been in regular clinical usage for a range treatment; those with a known history of any systemic disorder of inflammatory and immune-mediated conditions for over such as anemia (excluded by routine hematological tests under 50 years. Triamcinolone acetonide is one of the most commonly consent); or if their oral ulcers are associated with ocular, dermal, used medium potency topical steroid in RAS with relatively good genital, or gastrointestinal symptoms; those on medications results apart from its other varied indications such as OSMF, LP, such as NSAIDs, chemotherapeutic drugs, or with a history of Burning mouth syndrome, eczema, psoriasis, allergies, and so on. systemic immunosuppressives; those with a known history of Triamcinolone acetonide 0.1% is used as a topical application, 2 to hypersensitivity to foods or drugs, history of tobacco, and alcohol 3 times a day, for the palliative treatment of aphthous ulcers. The usage in the recent 6 months period; pregnancy; and lactating side effects of corticosteroids are dose related, and topical steroids woman were all excluded from the study. From the total of 670 are generally well tolerated.9,10 pro formas, 601 pro formas met one or more of the exclusion Previously conducted studies show limited evidence to criteria. The remaining 69 subjects were randomized by computer significantly substantiate the clinical efficacy of topical curcumin software and allocated to 2 groups: 34 participants in group I and and topical triamcinolone acetonide in the management of 35 participants in group II. Group I participants were treated with aphthous ulcers based on various clinical variables. To our topical curcumin—“Curnext”: Curcuma longa 10 mg oral gel 2% knowledge, this single-center, interventional, blinded, parallel and group II participants were treated with topical triamcinolone comparison trial is the first of its kind conducted to evaluate the acetonide—“Kenacort”: triamcinolone acetonide oral paste 0.1%. All efficacy of topical curcumin gel and topical triamcinolone acetonide the participants were informed to report to the study investigator oral paste in recurrent minor aphthous ulcers in a professional on day 1 of their next episode of oral ulcer for clinical evaluation. student population with a followup period of 6 months by assessing The investigator informed the willing participants in detail 6 clinical variables that include site of the ulcer, size of the ulcer, regarding the nature of the study and its possible consequences. ulcer pain, healing period, frequency of recurrence, and number of To minimize the patient dropouts, only those students who ulcers, studied with appropriate statistical analysis. In this context, were willing to participate, willing to get a cure for their ulcer this study is an important addition to the existing literature. episodes, and willing to cooperate throughout the study period were selected, and no one was forced to accept. Privacy of all the study participants was ensured. Each participant had the right