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2021, Number 3

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Rev Odont Mex 2021; 25 (3)

Efficacy of mexican propolis from Apis millifera in the treatment of prosthetic stomatitis. Randomized controlled clinical trial

Jurado Castañeda, Emiliano1; Ramírez Martínez, Carla Monserrat1; Carrillo Miranda, Liborio2; Díaz-Barriga, Arceo Sandra3; Cabrera Contreras, Israel Adair4; Portilla Robertson, Javier5

Language: English/Spanish [Versión en español]
References: 25
Page: 204-214
PDF size: 342.75 Kb.


ABSTRACT

Objective: To determine the therapeutic efficacy of 1.5% Mexican propolis gel compared to 2% miconazole gel (Daktarin®) in the treatment of denture stomatitis (DS). Material and methods: A double-blind randomized controlled clinical trial was carried out in a sample of 58 patients with DS according to the Newton scale. The specimens were divided by simple random sampling into two groups: "miconazole" (N = 30) and "propolis" (N = 28). The cumulative incidence (CI) and relative risk (RR) of the resolution of DS were determined. Results: The results showed no statistical significance (p < 0.05) since the Mexican propolis gel had an efficacy (CI = 80%) similar to miconazole (CI = 89.2%) in the clinical resolution of DS. In all cases, there was total absence of Candida sp at the end of the intervention. Conclusions: Mexican propolis gel proved to have potential for the treatment of DS. However, new studies are required to evaluate the role played by other variables such as salivary flow, as well as the state and type of prosthesis.



INTRODUCTION

Denture stomatitis (DS) is a chronic infection caused by Candida albicans that affects the alveolar and palatal mucosa in people with removable dental prostheses (RDP) with a prevalence of 70%.1,2 Null or poor hygiene, as well as long term contact with the mucosa are the main causes associated with DS1,3 where C. albicans finds the conditions to cause localized infection.4-8 Treatment is based on the standardization of hygiene measures after diagnosis,9 in addition to antifungals such as nystatin suspension or miconazole gel (Daktarin gel®).2,10 The latter has been used for 40 years with favorable results.11 However, failures in antifungal therapy have been described,2,12 so it is necessary to research new alternatives.

Propolis is a phytomedicine with therapeutic properties7 and due to its analgesic and biocidal potential, its usefulness in dental materials is a subject of research.7,8 It is a natural resin with a variety of biological properties developed by bees of the Apis millifera species for the protection of the hive12 and it also has antifungal activity, which is why it has been used in both in vitro and in vivo research in the therapeutic management of fungal infections.12,13-15 Mexico has areas where propolis has the necessary biological properties for its application as an alternative natural agent in the treatment of DS.12,16 As far as we know, in this country there has been no research on its therapeutic efficacy for clinical use. The aim of this research was to determine the therapeutic efficacy of a 1.5% Mexican propolis gel in the treatment of DS.



MATERIAL AND METHODS

From August 2016 to February 2017A, a parallel double-blind randomized controlled clinical trial was conducted in men and women aged 40 to 60 years with RDP with a clinical diagnosis of DS evaluated at the Oral Medicine clinic of the División de Estudios de Posgrado e Investigación Facultad de Odontología Universidad Nacional Autónoma de México (DEPeI FO UNAM). Volunteers had to be carriers of partial or total RDP of acrylic, acrylic metal, or nylon (flexible) regardless of the useful lifetime and that they emphatically followed the recommended habits and hygienic measures. This research was endorsed and approved by the bioethics committee of the FO UNAM. It was essential to inform about the advantages and disadvantages of both therapies, as well as the signing of the informed consent for the voluntary participation of potential candidates. Candidates, who suffered from a decompensated systemic disease, with antifungal treatment during the last month, immunosuppressed, those with chronic periodontitis, as well as those with a history of frequent allergies or sensitive to propolis, were excluded.

The oral cavity was clinically evaluated to identify erythema associated to DS using the Newton scale17 (III = papillary hyperplasia, II = generalized erythema, I = mild/focal erythema, and 0 = absence). At the same time, a microbiological sample was taken from each selected volunteer using a sterile swab, which was slipped over the affected mucosa, then immersed in a test tube with brain-heart infusion and left, in a microbiological culture oven at 37 oC to stand for 36 hours. Subsequently, with a loop, it was taken from the cloudy area and sown in a Petri dish with sabouraud® Agar using the simple striation technique to be left in a culture oven at 37 oC again for 36 hours. After this time, the Candida sp colonies were counted, using a colony quantifier. For this, we used the Colony Density System (CDS: 0 = absence, 1 = from 1 to 9 colonies, 2 = 10 to 100 colonies, 3 = more than 100 colonies and 4 = uncountable) used by Amanlou et al. in 2006.18

Related to prostheses, those that could be stabilized in terms of their surface quality, retention and functionality were evaluated, as well as those that had to be completely replaced due to their poor condition. Table 1 summarizes the maneuvers performed at the RDP in order that all the volunteers presented the same conditions prior to the interventions. Subsequently, the basal salivary flow (BSF) and stimulated salivary flow (SSF) obtained from total saliva by the spitting technique were determined.19 This made it possible to identify those participants with normal salivary flow (NSF), low (LSF) and high (HSF), which is of interest for the present research since it is presumed that a low flow may be a factor that hinders the resolution of DS.

Intervention and masking protocol

The volunteers underwent the experimental (propolis) and control (miconazole) treatments for twenty-one days. The drugs were poured into identical dosing metal cylinders with a capacity of 200 mL. For masking purposes, each of the cylinders was placed in a box with a unique presentation, so that neither the researcher nor the volunteers knew the drug being administered. It was essential to provide standardized hygiene instructions (including placement in bicarbonate solution overnight) in writing, as well as a dosage schedule to ensure that it was applied in a timely and proper manner. Each box was labeled with a color previously established for the two groups. A person outside the interventions preset the color blue for miconazole group, and white for propolis group.

Finally, the volunteers who met the selection criteria were placed in one of the groups following an order determined by simple randomization with a coin. A parallel standard posology was indicated that consisted of applying the treatment three times a day for ten minutes, twenty-one days. The volunteers had to spread the gels on the prosthetic base and later place it in the mouth. Measurements were carried out at the beginning (t0), at seven (t1), at fourteen (t2) and at twenty-one days (t3). At the end of the therapeutic administration, the color corresponding to each group was evidenced for statistical analysis. The 1.5% propolis gel was made for the purpose of this research and was provided by the Beekeeping Department of the Facultad de Estudios Superiores Cuautitlán de la Universidad Nacional Autónoma de México.

Statistical analysis

A sample size calculation was performed for the difference in proportions, assuming a difference of 15%. To determine the efficacy of propolis, a superiority hypothesis was established with a significance value of 0.05 using the cumulative incidence (CI), relative risk (RR) and chi-square with confidence intervals. The above based on intention-to-treat analysis.



RESULTS

In the period from August 2016 to January 2017, there were 81 potential candidates of which 23 were excluded because they presented some exclusion criteria or were aware of the benefits of propolis. Finally, the (n) for the present study was 58 participants (Figure 1).

Table 1 shows the baseline data of the 58 participants who constituted the total sample before and after being placed in the respective groups. Grade II DS cases predominated with 53.4%. Only one case of grade III (1.7%) was included in this group to facilitate statistical analysis. The baseline CDS of Candida sp in the total sample and between groups are summarized in the second row of Table 1. Regarding baseline SF results, 75.8% of volunteers were identified with NSF while 24.1% presented LSFo. The baseline results related to the stabilization of the prostheses showed that 58.3% of the total sample did not require any maneuver due to their good condition while the remaining percentage required polishing (20.6%). In this sense, 46.6% were rigid acrylic-based prostheses. The t1 analysis revealed a cumulative incidence (AI) of clinical resolution of PS of 25.05% and 23.3% respectively in the "miconazole" and "propolis" groups.

Table 2 summarizes the results at seven days of exposure without showing statistically significant differences (p < 0.05). At t2, an AI of 82.1% clinical resolution was observed in the "miconazole" group while in the "propolis" group it was 76.6%, with a resolution percentage of 79.3% in the total sample. At t3 the percentage of resolution in the "miconazole" group was 89.2% while in the "propolis" group it was 80%. The results show that both drugs have similar efficacy without showing statistically significant differences (p < 0.05/CI 0.71-1.1) indicating that propolis is inferior to miconazole in PS resolution. On the other hand, the results of the CDS of Candida sp at t3, were conclusive with a total absence in both intervention groups.

Table 3 summarizes the results of the FS analysis, prosthesis stabilization, type of material, sex, and its relationship with the final result. It is noteworthy that 92.8% of the 14 cases with LSFo resolved satisfactorily at t2 and the same percentage was maintained at t3, with no statistically significant differences. Concerning the prosthetic material, it was noteworthy that the prevalence of erythema at t3 was maintained in 7 (77.8%) of 9 cases in those participants who wore flexible dental prostheses. The results of prosthetic stabilization at both t2 and t3 showed equivalent resolution for those who had not received stabilization (p < 0.05/95% CI 0.97-1.7). As for sex, female sex was predominant without playing a specific role in the outcome. Finally, no participant reported side effects and reported good acceptability in both treatments.



DISCUSSION

In our knowledge, few studies address the mechanism of action of propolis against C. albicans, the results of Quintero Mora and collaborators in 201116 showed that Mexican propolis from the region of Cuautitlán Izcalli, State of Mexico inhibit the ADH1 and PIK1 genes involved in the pathogenesis of C. albicans, which is why it was decided to use propolis from this region, ensuring its procurement, processing, and quality control as required by the official propolis standard (NOM-003-SAG/GAN-2017). On the other hand, clinical studies demonstrating its application for the treatment of DS are also scarce.20-23 This trial is the first of its kind in Mexico and is also the one with the largest sample size (n 58) unlike previous studies whose samples were forty-five,20 twelve,21 thirty,22 and forty23 participants with favorable results in more than 80% as in our study. Our research coincided with those of Santos21 and Pina23 in intervening two study groups with similar vehicles (gel). Regarding the distribution by sex, the female sex was predominant with 79.3%, similar to other studies20-23 in which the percentage was 60, 65, 84.4 and 85% respectively, however, no differences were identified. Therefore, we consider it necessary to carry out studies with a homogeneous proportion to identify whether or not there is any difference.

The participants were selected with special care from the prosthetic perspective, something unprecedented, and as a result, 58.3% of the prostheses were found to be in good condition while 41.2% needed stabilization. The high prevalence of DS (70%) in RDP carriers is associated with multiple factors that play a role in its pathogenesis, such as poor hygiene and uninterrupted contact with the mucosa,24 however, new studies are required to describe the probable role that the state or conditions of these devices could play in the pathogenesis of DS, it is for this reason that the decision was made to stabilize the prosthesis because it is indispensable that the prosthesis is in good condition for the efficacy of antifungal therapy to be successfully carried out in the treatment of DS.1,2,24 The success of DS treatment also depends on hygienic measures,1,24 which is why previous studies choose to standardize participants before performing interventions, for oral and prosthesis hygiene. We consider that, although hygienic habits are indispensable for the success of the treatment, not all affected persons present prostheses with the same characteristics, hence the need to evaluate the prosthetic appliance from the physical and functional point of view. Our results indicate that there are no statistically significant differences in the resolution of DS concerning those who underwent stabilization (p < 0.05/95% CI 0.97-1.7). Regarding the time of use of the prosthesis, only in the study by Pina et al.23 did they perform an analysis of the meantime of use in their study groups, being 11 ± 9 and 15 ± 15 years. In our sample, the time of use was not considered due to the great discrepancy presented by the participants at the time of selection.

The association of mechanical method, brushing, chemical method, astringent solutions, and detergents are described as the most effective elements in cleaning and reduction of microorganisms.3,5,10,25 It was decided to indicate the use of bicarbonate in dilution to place the prosthesis at night during the time the treatment was indicated, which is not reported in previous studies. It is known that saliva plays a fundamental role in oral homeostasis, so a decrease in its flow favors opportunistic infections,2,10 in that sense, in previous studies people with this condition (xerostomia) were discarded.20-23 Despite this, participants with the decreased salivary flow were considered because only 24.1% of the sample presented low flow, in addition, it could not be demonstrated that this condition could interfere with the therapeutic efficacy in both treatments (p < 0.05) although it would be pertinent to review it in subsequent studies as one of the main research objectives. The 1.5% propolis gel formulation showed similar efficacy concerning the clinical resolution of DS (about 90% of the total sample at t2), as well as the elimination of Candida sp colonies (p < 0.05). Ensuring that participants apply the treatments according to the established dosage is always a challenge in clinical trials, so each participant was provided with an itinerary to control the applications with the help of family members, as well as application instructions, which were found in the packets with the drug corresponding to the group to which they belonged. Santos et al.21 reported a total resolution of DS after 14 days of exposure to 20% propolis gel when compared to nystatin 100,000 IU, however, they did not take into account variables such as prosthetic condition and type of material, which could play a role in the therapeutic efficacy. In this sense, only the prosthesis design (partial or total) has been reported as a characteristic in their study population, but not as a biasing or confounding factor. Our results reveal that the type of prosthetic material could be related to the therapeutic efficacy in both treatments as a confounder since when analyzing the overall result controlling for the type of material such as flexible prostheses in which DS prevailed in 7 of 9 cases (77.8%) despite 21 days of exposure, it could be assumed that flexible prostheses perpetuate PS, even with the absence of Candida sp colonies (p < 0.05).

Product acceptability is important for patient adherence to treatment, in our study we reported a good acceptance by the participants to propolis gel, coinciding with previous studies.20-23



CONCLUSIONS

The 1.5% Mexican propolis gel was shown to have similar efficacy to that of miconazole (Daktarin® 2% gel) in the treatment of denture stomatitis; however, there are different factors that interact or affect this condition. We consider it necessary to promote new research to obtain reliable results that guarantee the eventual implementation of this promising therapy as an alternative for the treatment of denture stomatitis.



ACKNOWLEDGEMENTS

CD. Esp. Gisela Dagmar Aguilar Kleimann for her valuable participation in the randomization process and assignment to intervention groups.


REFERENCES

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AFFILIATIONS

1 Adscrito al Departamento de Patología, Medicina Bucal y Maxilofacial de la División de Estudios de Posgrado e Investigación. Facultad de Odontología. Universidad Nacional Autónoma de México.

2 Jefe del Módulo de Apicultura y adscrito al Centro de Enseñanza Agropecuaria Campo Cuatro de la Facultad de Estudios Superiores Cuautitlán. Universidad Nacional Autónoma de México.

3 Investigadora del Departamento de Ciencias Biológicas Campo Uno de la Facultad de Estudios Superiores Cuautitlán. Universidad Nacional Autónoma de México.

4 Adscrito al Centro de Enseñanza Agropecuaria Campo Cuatro de la Facultad de Estudios Superiores Cuautitlán. Universidad Nacional Autónoma de México.

5 Coordinador del Departamento de Patología, Medicina Bucal y Maxilofacial de la División de Estudios de Posgrado e Investigación, Facultad de Odontología. Universidad Nacional Autónoma de México.



CORRESPONDENCE

Emiliano Jurado Castañeda. E-mail: juce2730@gmail.com




Received: Septiembre 2019. Accepted: Octubre 2021.

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