Comparison of Efficacy of Lycopene and Lycopene-Hyaluronidase Combination in the Treatment of Oral Submucous Fibrosis.

BACKGROUND: Oral submucous fibrosis (OSMF) is a chronic progressively scarring disease of the oral cavity. Lycopene is a powerful antioxidant obtained from tomatoes and has the highest singlet oxygen quenching capacity and a high capacity of quenching other free radicals in vitro among dietary carotenoids. Hyaluronidase is a substance prepared from the testes and semen of mammals that modifies the permeability of connective tissue through the hydrolysis of hyaluronic acid.
OBJECTIVE: To evaluate the efficacy of lycopene and lycopene-hyaluronidase combination, and to compare the efficacy of lycopene and lycopene-hyaluronidase combination in the treatment of OSMF. STUDY
DESIGN: The study consisted of 45 patients with OSMF divided into three equal groups. Patients in Group A were given Lycored 16 mg daily in two equally divided doses for 3 months. Patients in Group B were given LycoRed along with hyaluronidase intralesional injection of 1500 IU twice weekly for 3 months. Patients in Group C were given placebo capsules. Patients were evaluated after 3 months. The following parameters were recorded: mouth opening, visual inspection, palpatory findings, and burning sensation.
RESULTS: There was statistically significant change in mouth opening and burning sensation for lycopene and lycopene-hyaluronidase combination than in the placebo group in the treatment of OSMF, but the lycopene-hyaluronidase combination did not show any statistically significant change when compared with lycopene alone.
CONCLUSION: Lycopene appears to be a very promising antioxidant in the management of oral submucous fibrosis, both in clinical and symptomatic improvement.

INTRODUCTION

In simple terms, oral submucous fibrosis (OSMF) is a chronic progressively scarring disease of the oral cavity. Earlier thought to be a condition confined to the Indian subcontinent, China, and other regions of Asia, OSMF is now considered a global phenomenon due to increased numbers of migrant populations also demonstrating the condition. Over time, several treatment modalities have come into existence, but to date no single satisfactory cure has been found.[1]

Lycopene is a powerful antioxidant obtained from tomatoes and manufactured by the Lyc-O-Mato process where by it retains its natural proportions with other compounds in the marketed pharmacological preparations.[2] Lycopene has the highest singlet oxygen quenching capacity and a high capacity of quenching other free radicals in vitro among dietary carotenoids.[3] The inverse relationship between lycopene intake and cancer risk has been observed in particular for cancers of prostrate, pancreas, bladder, cervix, and oral leukoplakias because of its ability to modulate dysplastic changes.[34] New evidence has provided other explanations for the anticancer activity of lycopene by the upregulation of connexin and stimulation of gap junctional communication, an action that is independent of its role as an antioxidant.[56]

Hyaluronidase is a substance prepared from the testes and semen of mammals that modifies the permeability of connective tissue through the hydrolysis of hyaluronic acid, a polysaccharide found in the intercellular ground substance of connective tissue. Hyaluronidase can be given in combination with steroid preparations and shows better long-term results than when either agent is used alone. Improvement in health of mucous membranes, burning sensation, and trismus was observed while using hyaluronidase injections.[7]

In this study, the efficacy of lycopene and lycopene–hyaluronidase combination was evaluated and compared in the treatment of OSMF.

MATERIALS AND METHODS

After clinical examination, investigation, and biopsy, 45 patients with stage 2 OSMF (classified according to More et al.[8]) were included in the study. Patients were divided into 3 groups of 15 each. Patients in Group A were given LycoRed (Jagsonpal Pharmaceuticals company, New Delhi, India), containing 100% natural lycopene, with zinc, selenium, and phytonutrients) 16 mg daily in two equally divided dose for 3 months. Patients in Group B were given LycoRed along with hyaluronidase (Hynidase; Rallis India Ltd, Mumbai, India) intralesional injection 1500 IU twice weekly for 3 months. Patients in Group C were given placebo capsules. Patients were evaluated after 3 and 6 months. The following parameters were recorded: mouth opening, visual inspection, palpatory findings, and burning sensation. Mouth opening was assessed by measuring the interincisal distance using a vernier caliper, and burning sensation was assessed using visual analog scale. The responses were classified as complete, partial, stable, disease progression, and complications [Table 1]. Muscle exercise and cessation of the habit were common to all groups.

Table 1

Posttreatment assessment criteria

Posttreatment response	Visual and palpatory findings	Burning sensation	Mouth opening
Complete	Shift to stage 1	Burning sensation is completely absent that is shift to grade 0 (visual analog scale [VAS])	Increase in the mouth opening that ranging from 2 to 3 mm
Partial	Reduction in stage but not to stage 1	Reduction in grade without complete resolution (VAS)	Increase in the mouth opening that ranging from 0.4 to 1 mm
Stable	There was no response and no improvement
Disease progression	There is increase in stage	There is increase in grading (VAS)	Decrease in the mouth opening
Complications	Leukoplakia, malignant changes, dysphagia, hearing problems, change in phonation

RESULTS

Of 45 patients, 6 patients were lost on follow-up, 2 each from all the 3 groups. Efficacy of treatment was tested using an unpaired t test. There was statistically significant change in the mouth opening and burning sensation when the lycopene and lycopene–hyaluronidase groups were compared with the placebo group [Tables 2 and 3]. Though there was change in mouth opening, changes in burning sensation and visual and palpatory findings for lycopene–hyaluronidase combination compared with lycopene alone were not statistically significant [Table 4]. Posttreatment, lycopene and lycopene–hyaluronidase groups gave 100% complete response and control group 46.2% for increase in mouth opening [Graph 1]. In the case of burning sensation, partial response was observed in 100% of lycopene group, whereas for lycopene–hyaluronidase combination, complete response was seen in 7.2% and the rest showed partial response. In the case of control, 38.5% were partial response, 30.8% stable, and there was progression in 30.8% [Graph 2].

Table 2

Mean variation of burning sensation, mouth opening, and visual and palpatory findings between lycopene and control

	Group	N	Mean	Standard deviation	Standard error mean	P value
Burning sensation	Lycopene only	13	2.7692	0.83205	0.23077	0.000
	Control	13	0.0769	0.86232	0.23916
Change in mouth opening	Lycopene only	13	2.6154	0.86972	0.24122	0.002
	Control	13	1.2308	1.09193	0.30285
Visual and palpatory findings	Lycopene only	13	0.077	0.2774	0.0769	0.327
	Control	13	0.000	0.0000	0.0000

Table 3

Mean variation of burning sensation, mouth opening, and visual and palpatory findings between lycopene–hyaluronidase combination and control

	Group	N	Mean	Standard deviation	P value
Burning sensation	Lycopene with hyaluronidase	13	3.3846	0.96077	0.000
	Control	13	0.0769	0.86232
Change in mouth opening	Lycopene with hyaluronidase	13	3.3846	1.04391	0.000
	Control	13	1.2308	1.09193
Visual and palpatory findings	Lycopene with hyaluronidase	13	0.154	0.3755	0.153
	Control	13	0.000	0.0000

Table 4

Mean variation of burning sensation, mouth opening, and visual and palpatory findings between lycopene and lycopene−hyaluronidase combination

	Group	N	Mean	Standard deviation	P value
Burning sensation	Lycopene only	13	2.7692	0.83205	0.094
	Lycopene with hyaluronidase	13	3.3846	0.96077
Change in mouth opening	Lycopene only	13	2.6154	0.86972	0.053
	Lycopene with hyaluronidase	13	3.3846	1.04391
Visual and palpatory findings	Lycopene only	13	0.077	0.2774	0.558
	Lycopene with hyaluronidase	13	0.154	0.3755

Graph 1

Posttreatment response for mouth opening

Graph 2

Posttreatment—burning sensation

In the case of visual and palpatory findings, in lycopene group, none of them showed complete response, 7.7% showed partial change, and the rest everyone were stable, whereas lycopene–hyaluronidase combination showed 7.7% complete change, 7.7% partial, and the rest were stable. In the case of control 100% did not show any change [Graph 3].

Graph 3

Posttreatment—visual and palpatory findings

DISCUSSION

Lycopene acts via reducing the inflammatory process seen in OSMF by reduction of reactive oxygen species and modifies the expression of certain genes that play a key role in collagen deposition and collagen degradation.[9] It also upregulates lymphocytic resistance to stress and suppresses the inflammatory response. Hyaluronidase plays an important role in modifying the tissue permeability. In our study, hyaluronidase with lycopene when compared with lycopene only showed better results but it was not statistically significant.

This is the first study in which the efficacy of lycopene is compared against lycopene–hyaluronidase combination. Our aim was to evaluate and compare the efficacy of lycopene and lycopene–hyaluronidase. The mouth opening, burning sensation, and visual and palpatory findings were taken into consideration using the aforementioned methods.

Several studies exist that have assessed mouth opening in OSMF after using lycopene. A 2007 study by Kumar et al.[10] showed statistically significant increase in mouth opening, and in another study by Karemore and Karemore ,[11] it was seen that lycopene was effective in reducing the objective signs of OSMF as demonstrated by the improved maximal mouth opening in 69.56% of the subjects. Similarly, our study also showed a statistically significant change for lycopene and lycopene–hyaluronidase combination in comparison with control. When compared with lycopene, lycopene–hyaluronidase did not show statistically significant change in mouth opening.

Burning sensation in the case of OSMF is mainly due to epithelial atrophy, which is a sequel of juxtaepithelial inflammation, increased fibrosis, and compromised vasculature. Lycopene plays a key role in reduction of this inflammatory process and fibrosis, thus leading to epithelial regeneration and reduction of burning sensation. In terms of reduction in burning sensation, the mean reduction was more for lycopene–hyaluronidase combination, but the change was not statistically significant when compared with lycopene alone.

Similarly neither lycopene, nor lycopene–hyaluronidase combination gave a statistically significant change in the case of visual and palpatory findings and most of these changes appeared irreversible.

A study by Sunderraj et al.[12] based on similar parameters showed 80% complete response and 20% stable response. According to our study, we found that management of OSMF with lycopene alone showed a significant increase in mouth opening and relief in burning sensation whereas, management with lycopene in combination with hyaluronidase showed marginally better results, but these were on the whole not statistically significant.

The frequency of malignant change in patients with OSMF ranges from 3 to 6%. In a 10-year follow-up study in Ernakulam district, Kerala, India, Gupta et al. reported malignant transformation in 2.3% patients with OSMF.[13] From the same area and patient group, 66 patients were followed up for a period of 17 years by Murti et al.,[14] who reported a malignant transformation rate of 7.6%. With a longer follow-up of same group, the malignant transformation rates could depict further increase.[14] Anticarcinogenic effect is considered as one of the most important actions of lycopene. Lycopene is found to exhibit the highest physical quenching rate constant with singlet oxygen. The effect of lycopene in oxidative status among OSMF patients has not been assessed in our study. But the study population is under constant supervision with periodic follow-up.

There were few limitations for this study. Six patients initially enrolled in the study were lost to follow-up. Previous studies have shown the effect of hyaluronidase on long-term basis, which could not be assessed in our study.

CONCLUSION

Lycopene as a purely oral delivery therapeutic modality attained reliable results in the quick span of a month. This was quicker than most other medical treatments under consideration today. Thus, we may conclude that lycopene appears to be a very promising antioxidant in the management of OSMF. As there are very few studies conducted with lycopene in the treatment of oral premalignant lesions and conditions and oral cancer, further studies should be carried out with larger sample sizes and longer follow-up to confirm its efficacy as well as determination of the maximum dose of lycopene that can be administered safely. Even though, hyaluronidase did not give a statistically significant result, further follow-up and research have to be conducted on the same.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.