Comparison of Virgin Coconut Oil with 5% Amlexanox in Management of Minor Recurrent Aphthous Ulcers - A Randomized Control Trial

Introduction

Recurrent Aphthous Ulcer (RAU) is a common painful inflammatory ulcerative disorder of the non-keratinized oral mucosa which causes difficulty in eating, swallowing and speaking. It presents as a distinct, shallow, round ulcer with a necrotic centre covered by a pseudo membrane and is surrounded by a raised erythematous halo around the border, with a prevalence in the general population ranging between 5%and 60%.^1,2

The etiopathogenesis of RAU so far remains not fully understood. The potential trigger factors include: immunologic, genetic predisposition, viral and bacterial infections, increased oxidative stress, etc.² The genetic risk factors that modify the individual susceptibility to RAU include various DNA polymorphisms distributed in the human genome, especially those related with the alterations in the metabolism of interleukins (IL- 1b, IL-2, IL-4, IL-5, IL-6, IL-10, IL-12), interferon c(IFN-c) and tumor necrosis factor alpha (TNF-α).³ According to various studies, potential factors that modify the immunologic response and invoke recurrent aphthae in predisposed subjects are bacterial(Streptococcus oralis, Helicobacter pylori) and viral antigens(Herpes Simplex virus, Varicella-Zoster virus, Cytomegalovirus, Adenoviruses). The increased production of IL-2, IFN-c and TNF-α by the peripheral blood mononuclear cells is observed both in the acute and remission phase of the disease.⁴

Various treatment modalities available include antibiotics, steroids, immunomodulators/immuno suppressors which if used for a long duration may cause various adverse effects.² Another clinically proven drug by US FDA for the treatment of Aphthous ulcers is 5% Amlexanox as topical oral paste but the adverse effects include contact mucositis with tingling sensation, burning sensation and erythema. Pertaining to the efficacy, side effects of the commonly used drugs, the advent of new drugs and the chemical entities in natural products represents an alternative for the development of novel drugs. In this context, virgin coconut oil (VCO) may be an alternative to the conventional treatment modalities which is been compared with US FDA approved 5% amlexanox oral paste.

Virgin Coconut oil (VCO) which is a naturally processed, chemical free and additive free product from fresh coconut meat, which has not undergone any chemical processing after extraction. It is the purest form of coconut oil, water white in color, contains natural vitamin E and has not undergone any hydrolytic or atmospheric oxidation as attested by its very low free fatty acid content and peroxide value. It has a mild to intense fresh coconut scent. Virgin coconut oil is different from coconut oil is that coconut oil is extracted by pressing copra that has been exposed to very high temperature or sunlight whereas VCO is extracted from fresh coconut meat which has been pressed to get coconut milk and has been centrifuged to separate oil from milk. Virgin coconut oil (VCO) is known for its medium chain triglycerides (MCTs). Studies have been conducted with VCO as an anti-ulcerogenic activity, antifungal activity, antibacterial activity, analgesic activity; promote apoptosis in cancer cells also shows increase in quality of life in breast cancer patients undergoing chemotherapy and radiotherapy.

Very few studies have been focused on the role of VCO on oral mucosal lesions.

Hence, the aim of this study is to determine the efficacy of VCO in management of signs and symptoms of minor recurrent aphthous ulcers which have been compared with the US FDA approved 5%Amlexanox.

Methodology

The study was approved by the Institutional Review Board.

Source of Data

Patients attending the Department of Oral Medicine and Radiology, Coorg institute of dental sciences, Virajpet, Karnataka, India in the year 2016-2018 were recruited in this study. A written consent was obtained from the patients.

Inclusion Criteria

1. History of recurrent ulcers reporting within 48 hrs.
2. 18 to 50 yrs.
3. Ulcers size less than 1 cm. 
4. Patients willing to participate .

Exclusion Criteria

1. History of systemic diseases
2. Topical application or any systemic medications two weeks before trial.
3. Known drug allergies.
4. Pregnancy and lactation.
5. Patients with dental appliances
6. Altered hemogram values.

Method of collection of VCO

VCO which is collected from an authorized coconut mill, “Coconut processing unit of the Anjarakandi Farmers service Co-operative Bank ltd” Chakkrakal Mamba, Kannur dist.Kerala.

Processing of VCO done in the mill

De husking of coconuts followed by Deshelling after which removal of brown testa/pairing followed by blanching and draining further followed by disintegration and milk extraction. The separation of milk and oil in water emulsion at the end is the filtration in which the oil was passed through the filter press. Vacuum drying of coconut oil was done to remove the moisture present in that and finally packed in consumer packs.

The purity of VCO was confirmed by biochemical evaluation done in Dept of Biochemistry.

Test for saponification

1g of oil is weighed in a tarred beaker and dissolve in about 3 ml of ethanol Quantitatively contents of the beaker has been transferred three times with a further 7 ml of the solvent to which 25 ml of 0.5 N alcoholic KOH are added and mixed well another condenser was settled up as the blank with all other reagents present except the fat .Both the flasks was placed in a boiling water bath for 30 minutes and cooled to room temperature phenolphthalein indicator was added to both the flasks and titrated with 0.5 N HCl .The endpoint of blank and test was noted The difference between the blank and test reading gave the number of milliliters of 0.5 N KOH required to saponify 1g of fat.

Test for free fatty acids

10 g of oil is dissolved in 50 mL of the standard solvent in a 250 mL conical flask to which phenolphthalein is added and the contents were titrated against 0.1 N potassium hydroxide until pink color persists for fifteen seconds.

Armamentarium

For clinical evaluation

• Mouth mirror, Tweezer, William’s periodontal probe, metallic scale, sterile gauze, Virgin Coconut Oil(VCO) which is collected from an authorized coconut mill,” Coconut processing unit of the Anjarakandi Farmers service Co-operative Bank ltd” Chakkrakal Mamba , Kannur district, Kerala, India, Lexanox (Amlexanox oral paste 5%) manufactured by Macleod’s Pharmaceuticals Mumbai Maharashtra, India.

For biochemical tests with VCO

• Beaker, conical flask, volumetric flask, measuring cylinder, round bottom flask, Glass stirrer, Test tubes, Bunsen burner, spatula, Tripod stand, Rotary shaker, Rotary evaporator, Funnel.

Study Procedure: 45 patients were initially recruited for the study they were explained regarding the treatment protocol and were instructed to adhere to the same, out of which 5 patients failed to report and were lost follow up (3 from Group A and 2 from Group B failed to report back on 3rd and the 5th day). Hence 40 patients who completed the trial were included for evaluation. The patients were informed that the study would involve clinical examination, photographs and blood investigations. The patients were instructed to report for follow up on 3rd and 5th day. All patients underwent routine hematological examination. Patients details were recorded in the proforma designed. Clinical examination was performed to assess the site and size with a calibrated William’s graduated periodontal probe and pain was graded using Visual Analog Scale (VAS) 0-10 on all three visits (day 1, day 3 and day 5).(Figure1a,1b,1c and 2a,2b,2c) The patients were randomly (lottery method) divided into two groups-Group A (20 patients) and Group B (20 patients). In Group A Patients were given 150 ml VCO bottle with which they were instructed to swish 10ml oil in mouth, three times a day for 5 minutes for five consecutive days (after meals) and were asked to refrain from eating, drinking and rinsing for at least 30 minutes after the swish. In Group B patients were instructed to squeeze a dab of 5% Amlexanox paste approximately 1/4 inch (0.5cm) onto a cleaned finger tip to the ulcer site three times a day for five days (after meals) and were asked to refrain from eating ,drinking and rinsing for at least 30 minutes after topical application. In both the groups they were informed about the possible allergic reactions and were instructed to terminate the use of the product in the event of any adverse reaction and to report immediately.

Statistical Analysis

The data was collected, coded and fed in SPSS (IBM version 23) for statistical analysis. The descriptive statistics included mean, standard deviation, frequency and percentage. The inferential statistics included both parametric and non parametric tests. The parametric tests included Paired t test, Independent t test and one way ANOVA test followed by Post hoc Tukeys test. The non parametric test included the Chi square test. The level of significance was set at 0.05 at 95% Confidence Interval.

Results

This study demonstrated a high statistical significant difference within the groups in ulcer healing and pain reduction (p=0.00) in groups A and B. When the outcomes were compared between the groups, no reduction in ulcer size (p=0.682) and pain (p=0.308) was observed on the 3rd day. However a significant reduction in pain was present on the 5th day (p=0.02) in group A, and no significant reduction in ulcer size was noted (p=0.083). (Table-1, 2, 3, 4)

Discussion

Virgin coconut oil is known for its medium chain triglycerides (MCTs). The most important medium chain fatty acid found in VCO is lauric acid. It constitutes Lauric acid (49%), myristic acid (18%), palmitic acid(8%). Lauric acid possess powerful antimicrobial properties capable of destroying disease causing bacteria, fungi, viruses and parasites.⁵

The primary goal of RAU therapy are; relieving pain, reduction of ulcer duration, reduction in frequency and severity of occurrence and restoration of normal oral function. In the present study pain relief was measured by VAS and healing of the ulcer was measured by their reduction in size.

Statistically highly significant reduction in the size of ulcers was observed in group A (p=0.00).This could be due to the activity of Monolaurin, the monoglycerides of Lauric acid which are the active components of VCO.5 VCO’s anti-inflammatory, inhibitory effect on chronic inflammation could result in reducing the transudative weight, granuloma formation, and serum alkaline phosphatase activity.⁶ Also VCO is known for fastened wound healing property due to the expression of proteolytic enzymes, which in turn affect the host tissue remodeling process and the active synthesis and deposition of matrix proteins in the granulation tissues. This is evident from the higher turnover and cross-linking of collagen, in wounds treated with VCO. Glycohydrolase activities were also found to be increased due to a higher turnover of collagen.⁷

In group B follow a significant reduction in the size of ulcers was observed on day 3 and 5 (p=0.00). This is in accordance with previous studies done by Jie et al, Murray et al, Rodriguez et al, Molla et al and Suraksha et al.^8,9,10,11,12This healing with amlexanox has been attributed to its anti-allergic and anti- inflammatory activity. Amlexanox 5% topical oral paste inhibits the formation and release of histamine and leukotrines from mast cells, neutrophils, and mononuclear cells. Histamine and leukotrines are vasoactive inflammatory mediators which can increase the permeability of vessels and therefore cause swelling of the involved tissues, but also contribute to inflammation by affecting the functions of other leukocytes in the involved area.¹³

Although no statistical reduction in ulcer size was observed between the groups, the mean size of ulcer was lower in the VCO group on days 3 and 5 (2.45±2.03) (0.15±0.48) respectively. It is worthwhile to note that the mean ulcer size was higher at baseline in the VCO group (6.35±1.36).

There was highly statistical significant reduction in pain score within each group (p=0.00) on day 5. The mean VAS between the groups showed no statistical significant difference on day 3, however there was statistical significant reduction of pain on 5th day (p=0.02) with higher reduction in group A. This improved pain reduction in group A could be due to the activity of monolaurin, the monoglycerides of Lauric acid in VCO causing antiinflammatory property which inhibit the biosynthesis of PG and decrease the sensitivity of vessels to bradykin and histamine and due to its analgesic property in which there is writhing response due to peripheral effect by blocking the synthesis or release of the endogenous substance responsible for pain.⁷

The result of our study is comparable to a recent study conducted to evaluate the efficacy of VCO in the management of RAS. However direct comparisons are not possible due to differences in study design.

In a comparative study, no significant difference was observed in reduction of ulcer size and pain when VCO was compared with triamcinolone with a sample size of 20 (p=0.373) (p= 0.082) respectively.¹⁴

The safety of amlexanox has been previously evaluated in several acute and chronic safety studies in animal and was shown to be non carcinogenic and to have no effect on reproductive performance at the dose of 300mg/kg/ day. The expected dosing for treatment of aphthous ulcer was found to be 60mg of paste four times a day for about 12 days.¹⁵ Amlexanox has not reported any adverse effects in the present study.

It has been shown that most of the systemic absorption of Amlexanox probably results from the gastrointestinal tract after swallowing 5% Amlexanox paste rather than directly through the ulcer. The incidence of adverse events potentially related to 5% Amlexanox paste was very low.

It is unlikely that VCO when used topically as in the present study will result in serious adverse effects. Till date studies conducted using VCO did not show any adverse effects whereas with the use of refined coconut oil adverse effects such as damage to kidneys due to accumulation of ketone bodies, Laxative effects have been reported in some studies at doses more than 3 tablespoons of oil daily.¹⁶

Recently a lecture by Harvard university professor Karin Michaels titled ‘Coconut oil and other nutritional errors’ created controversy as she called coconut oil as ‘pure poison’ due to its high proportion of saturated fats. However, several other studies have suggested that moderate use of coconut oil is beneficial for health.¹⁷

VCO has better qualities as it is available in its purest form and does not undergo any kind of chemical refining, bleaching or deodorizing unlike commercially available coconut oil. Therefore the use of VCO is justified considering its health benefits and safety in children and pregnant woman.

To the best of our knowledge, this is the first clinical trial conducted in which VCO has been compared with US-FDA approved Amlexanox 5%. Considering safety, availability and low cost, VCO could be an alternative therapeutic modality in the management of RAS.

Limitations and Future Directions

One of the limitations of this study was the small sample size. Larger sample size would have allowed for stronger statistical analysis and would also aid in identifying and grouping of patients for a more robust analysis. Inability to perform blinding is another limitation in this study. Another limitation of the study is the dependence on patient’s history regarding duration and episodes at the baseline which could lead to inconsistencies. In this study other end points like recurrence and quality of life was not evaluated due to difficulty in long term follow up.

Conclusion

The study demonstrated a highly statistical significant difference within the groups in ulcer healing and pain reduction (p=0.00) in group A and B. When the outcomes were compared between the groups, no reduction in ulcer size (p=0.682) and pain (p=0.308) was observed on the 3rd day. However a significant reduction in pain was present on the 5th day (p=0.02) in group A, with no significant reduction in ulcer size (p=0.083). This study suggests that VCO could be used as an effective and safe drug in management of signs and symptoms of RAU. It is known to be edible oil with no known adverse effects; it could be a safe therapeutic alternative in children and pregnant women. Further studies with larger sample size are required to confirm the efficacy of VCO in the management of signs and symptoms of RAU.

Conflict of Interest

None.