Effectiveness of Fenugreek as an Adjuvant in the Management of Oral Potentially Malignant Disorders: A Randomized Controlled Trial

INTRODUCTION

Oral cancer accounts for about 3% of all malignancies, posing a major global public health threat, with the highest incidence, mortality, and disability-adjusted life year, among cancers.^1,2 It often results in poor quality of life and increased health expenditures. Oral potentially malignant disorders (OPMD) are chronic conditions that precede oral cancer, with lesions in the oral mucosa at increased risk of malignant transformation (1.4–7%).³ Common OPMDs include leukoplakia, oral lichen planus (OLP), and oral submucous fibrosis (OSMF).

Leukoplakia is defined as a predominantly white plaque of questionable risk, excluding other known diseases.⁴ The global prevalence of leukoplakia is 2%, and in India, it ranges from 0.2 to 5.2%, with a malignant transformation rate of 0.13 to 10%.^5,6 The OLP is a chronic inflammatory disease with a global prevalence of 1.01% and 2.6% in India, with an annual malignant transformation rate below 1%.^7,8 The OSMF is a chronic disease affecting the lamina propria of the oral mucosa, progressing to deeper tissues, commonly found in regions with a culture of betel nut chewing.⁹ The global prevalence of OSMF is 15%, and 6.42% in India, with a malignant transformation rate of 2–8%.¹⁰

Routine treatment for OPMDs includes pharmacotherapy, surgery, and radiotherapy, with recent additions of lasers and cryosurgery.¹¹ Management often involves cessation of tobacco and alcohol use. Leukoplakia can be treated with vitamin A, topical bleomycin, and systemic 13-cis retinoic acid.¹² The OLP treatment aims to reduce symptomatic outbreaks using topical and systemic corticosteroids like prednisone, along with oral hygiene measures.¹³ The OSMF treatment includes intralesional dexamethasone injections and topical triamcinolone acetonide.^14,15

Natural therapies are becoming popular for treating various diseases due to their limited side effects and potential for improving quality of life.¹⁶ Medicinal plants and natural products like tulsi, curcumin, lycopene, chamomile, aloe vera, green tea, colchicine, spirulina, and raspberry extracts are used for managing potentially malignant oral diseases due to their immunomodulatory and antioxidant properties.^17–21 Fenugreek (Trigonella foenum-graecum Linn.) has attracted attention for managing various systemic diseases. Traditionally used in Indian medicine for digestive and mucosal conditions, fenugreek exhibits antidiabetic, antifertility, anticancer, antimicrobial, and antiparasitic effects, with radical scavenging activity reported from its extracts. Fenugreek seeds have shown potential in stimulating insulin secretion, improving glycemic control, and enhancing periodontal health, but scientific evidence for their role in oral cancer prevention remains limited.^22,23

Hence, this study determined to evaluate the effectiveness of fenugreek as an adjuvant in managing OPMDs namely leukoplakia, lichen planus, and OSMF. The objective was to assess fenugreek’s effectiveness clinically and photographically in OPMD management. The hypothesis was that fenugreek in its natural form, used alongside standardized treatment protocols, may influence OPMD resolution.

MATERIALS AND METHODS

The study was designed as a randomized controlled clinical trial, conducted in accordance with the Consolidated Standards of Reporting Trials guidelines. It was carried out at a public teaching Dental Institution in Tamil Nadu, India, from January to September 2021 on the individuals reporting to out-patient department. The study protocol was reviewed and approved by the Institutional Review Board (IRB reference number: 4/IRB/2019). The trial was registered in the clinical trial registry of India (CTRI/2020/02/040893). The sample size required for the trial was calculated using G*Power software and was found to be 28. Hence, the sample size required per group was 14 participants.

Adults diagnosed with leukoplakia, lichen planus, and OSMF were included in the trial, while those with systemic illnesses, participating in other trials, or having hypersensitivity to fenugreek (such as nasal congestion, coughing, wheezing, facial swelling, or allergic reactions) were excluded. The purpose of the study was clearly explained to the participants. During a 9-month recruitment period, 40 subjects were assessed for potentially malignant oral disorders. After excluding 19 participants for various reasons, 21 subjects were included in the final study (Fig. 1). Allocation concealment was achieved using the sequentially numbered opaque sealed envelope technique. Subjects prediagnosed with OPMD in the Oral Medicine and Radiology Outpatient Department were randomly assigned to either the study group (SG) or the control group (CG) using computer-generated numbers. The final study population consisted of 10 participants in the SG and 11 in the CG. The sequence generation and randomization were conducted by a co-investigator using numbered envelopes. Written informed consent was obtained from participants, with information provided in either Tamil or English.

The demographic data and medical history of the subjects were recorded at the initial visit. Clinical and photographical assessment of the lesion was carried out every 15 days up to the follow-up period of 2 months in both groups. Clinical assessments of leukoplakia included measuring the lesion’s size in centimeters with a metal divider and millimeter ruler, following Van der Wal’s 2001 criteria. The shape of the lesion was categorized as linear, circular, or elliptical. Consistency was classified as soft, medium, or hard. Induration and ulceration were noted simply as present or absent. Clinical evaluations for OLP included checking for erythema, ulceration, and burning sensation. Erythema and ulceration were rated using a semi-quantitative scale, the Modified Oral Mucositis Index.^24,25 The burning sensation was measured on a visual analog scale from 0 (minimum) to 10 (maximum). Clinical assessments for OSMF included evaluating the burning sensation on a visual analog scale from 0 to 10, measuring mouth opening with a metal divider as per Mishra and Ranganathan criteria, and recording the presence or absence of blanching in the oral mucosa. Cheek flexibility was assessed by measuring the distance from the maxillary incisal midline to the cheek retractor during retraction, graded according to Patil et al. standards.^26,27

Trial drugs were dispensed in paper bags by an uninvolved assistant, and the co-investigator ensured that participants followed proper drug intake instructions. The chief investigator was blinded to the intervention details. Along with the trial drug−fenugreek in its natural form, standardized treatment protocol for three lesions was followed for SG, whereas those in the CG were administered only the standard treatment as per protocol guidelines. Since no previous studies were undertaken with fenugreek, advice for administration of fenugreek was sought from Siddha and Ayurvedha experts as well as from World Health Organization monograph on herbal medicine.²⁸ As per their guidance, the dosage for administration of fenugreek was fixed as 2 gm/day bid. This trial drug was weighed using a standardized digital apparatus (Selves Enterprises and B06XMZV7RH), pocketed in small sachet of 28 sachets and was dispensed to the SG group subjects. They were instructed to swallow fenugreek after food by 8 a.m. in the morning and 8 p.m. at night at 12 hours interval for 2 weeks to be repeated till 8 weeks of the trial period.

The intervention for the CG included intralesional injection of vitamin A 1,00,000 IU (Aquasol A) and topical application of triamcinolone acetonide 0.1% (Kenacort) for 2 months for leukoplakia. Subjects with oral lichen planus were administered prednisolone 5 mg/day (Wysolone), chlorhexidine mouthwash 0.2% (Peridex), and Zincovit once daily for 8 weeks. For subjects with OSMF, one capsule of SM Fibro once daily for 12 weeks along with dexamethasone 1.5 mL (Decadron) was given, and hyaluronidase 1,500 IU (Hynidase) with 0.5 mL lignocaine HCL (Xylocaine) was injected intralesionally biweekly and mouth exercise was advised as intervention for 2 months. Subjects in both the groups were instructed to adhere to the intervention protocol for a period of 2 weeks and to return after 2 weeks for outcome assessment till 8 weeks.

Compliance and attrition were secondary outcomes. Subjects in both groups were asked to return leftover medicine at subsequent visits. A co-investigator collected these and classified subjects as compliant or noncompliant based on whether they used at least 80% of the medicine (no more than one packet remaining). Compliance rates were calculated for each group separately. Lesion evaluations and photographic assessments (Figs 2 to 4) were conducted from baseline to 8 weeks. Subjects were reminded of follow-up appointments by phone and written instructions on their outpatient cards. At each visit, lesions were examined, and decisions about continuing treatment were made by the investigator.

Data were tabulated in Microsoft Excel and analyzed using IBM Statistical Package for the Social Sciences (Version 21.0). Descriptive statistics reported sociodemographic data. The Fisher exact Chi-square test assessed differences in lesion size, shape, and erythema between groups. The Friedman test and Mann−Whitney U-test compared the mean values of burning sensation, mouth opening, and cheek flexibility within and between groups, respectively. Significant within-group differences were further analyzed using the Wilcoxon signed-rank test post-Friedman test.

RESULTS

Out of 21 participants, 8 participants had leukoplakia; 5 had lichen planus, and 8 had OSMF. All participants were aged between 25 and 57 years, with a mean age of 42.59 ± 8.418 years (Table 1). Overall, male participants outnumbered females, except in the case of lichen planus, where females were more prevalent (Table 1).

Most participants presented with leukoplakia of the buccal mucosa (75%), typically bilateral with lesion sizes of less than 2 cm (Table 2). The lesions varied in shape, including linear, circular, elliptical, or combinations thereof. Postintervention analysis revealed no significant differences in parameters such as size and shape of leukoplakia between the groups during each follow-up (Table 3). Intragroup comparisons of size and shape also showed no significant differences between baseline measurements and each follow-up (Table 3).

Participants diagnosed with lichen planus presented with no ulceration but with mild to moderate erythema (Tables 2 and 4). Additionally, the majority reported a mild burning sensation, ranging from 0 to 5 on a scale of 0 to 10, observed in both groups (Table 4). There was no significant difference in erythema between the groups postintervention, at baseline, or during any follow-up visits (Table 4). Within-group comparisons showed no significant differences in burning sensation between follow-up visits (Table 5). Similarly, no significant difference in burning sensation was observed between the groups postintervention, at baseline, and at each follow-up visit (Table 5).

Most participants diagnosed with OSMF experienced a mild burning sensation, with mean values of (1.5 ± 0.707) and (1.67 ± 0.577) in the SG and CG after 2 months, respectively (Table 2). The mean mouth opening was 25 ± 7.165 mm in the SG and 27 ± 6.055 mm in the CG, while the mean flexibility was 21.5 ± 6.952 mm in SG and 21.5 ± 5.745 mm in CG after 2 months (Table 2). However, within-group analysis showed significant differences in burning sensation between baseline and the 4th follow-up in OSMF (p = 0.034) (Table 6). Similarly, significant differences were observed within groups in mouth opening (p = 0.016) and flexibility (p = 0.027) between baseline and the 4th follow-up, respectively (Table 6). There were no significant differences between the groups in terms of burning sensation, mouth opening, and flexibility in OSMF during any follow-up visits (Table 6). Though the measured parameters after trail intervention remained stable in leukoplakia and lichen planus, OSMF showed positive changes in burning sensation, mouth opening, and cheek flexibility in SG after 2 months.

DISCUSSION

Oral cancer represents about 3% of all malignancies, with many cases arising from OPMDs. The prevalence of OPMDs is 10.54%, with specific disorders such as leukoplakia, lichen planus, and OSMF ranging from 0.2 to 5.2%, 1 to 4%, and 0.2 to 2.3%, respectively. Leukoplakia, lichen planus, and OSMF have been identified as the most common OPMDs among the South Asian population.^{7, 29–32} Therefore, our trial specifically targeted these lesions.

To address the malignant transformation and reduce the mortality due to cancer, early detection, correct diagnosis, and timely treatment of OPMDs was required. This included regular dental examination and removal of implicated environmental and behavioral risk factors.^1,13 While various treatment protocols exist, natural products, due to their beneficial biological properties, offer advantages over conventional treatments, including overcoming chemoresistance, reducing cytotoxicity to healthy cells, and being cost-effective. These natural compounds show promise as adjuvant, neoadjuvant, and chemoprevention agents for OPMDs. Recent studies have explored the widespread use and beneficial properties of fenugreek, particularly its potential applications for various disorders.³³

Several studies have shown that fenugreek seeds exhibit anticancer properties across various cancer types. Research by Raju et al.,³⁴ Verma et al.,³⁵ and Khalil et al.,³⁶ demonstrated antiproliferative and cytotoxic effects against gastrointestinal cancers. Shabbeer et al.,³⁷ Alshatwi et al.,³⁸ and Alsemari et al.³⁹ found similar effects on breast cancer. Additionally, studies on hematological cancers and lung cancer^39–41 revealed inhibition of cell growth and tumor reduction. Azari et al. found out that fenugreek seed extract protected the gastric mucosa from injury, reducing the gastric erosion and ulceration against experimentally induced gastric ulcers in rats.⁴² The varied effects of fenugreek in humans were noted by Tavakoly et al.⁴³ for its anti-inflammatory and antioxidant effects in type 2 diabetes; Emtiazy et al.⁴⁴ identified fenugreek’s flavonoids effect on lipid peroxidation, thereby protecting against oxidative stress, with improvements in respiratory function. Bordia et al. found that a 2.5 gm dose twice daily significantly reduced cholesterol and triglycerides in coronary artery disease patients with non-insulin dependent diabetes mellitus.⁴⁵

Also, fenugreek in its naturally occurring form (seed) was found to exhibit anti-inflammatory, hypocholesterolemic, hypoglycemic, antioxidant, and antiulcer properties.^46,47 The seed proteins are reported to be responsible for the high antioxidant activity of fenugreek with an excellent amino acid profile (high amount of Glu, Asp, Lue, Thr, and Arg).⁴⁸ It has been successively administered for various cancers due to several important components such as trigonelline, diosgenin, and protodioscin. An important component of fenugreek, diosgenin, was a steroid saponin and has been reported to inhibit cell growth and induce apoptosis. The mechanism of action of diosgenin was proposed to be induction of apoptosis in HT-29 cells partially by inhibition of bcl-2 and by induction of caspase-3 protein expression.^33,34 A study by Jagadeesan et al. showed that diosgenin exhibits anticarcinogenic activity via reducing peroxidation reaction and marker enzymes by enhancing the intrinsic antioxidant defense system.⁴⁹

One of the main causes for the development of OPMDs was the increase in levels of oxidative enzyme and relatively increased oxidative stress. Fenugreek exerts its antioxidant activity by increasing the levels of antioxidants. In addition to the above stated advantages of using the fenugreek seeds, some of the other properties of fenugreek could have been masked on various forms of its formulation. Hence fenugreek in its natural form was used to evaluate its effectiveness on OPMDs in the present study. The systemic use of fenugreek employed in the present clinical trial was according to the World Health Organization Monograph on herbal medicinal plants.²⁸ To the best of our knowledge, no previous studies have been done to study the effectiveness of fenugreek in the management of OPMDs and hence, this is the first of the kind in administering fenugreek as an adjuvant for the management of OPMDs.

Leukoplakia was common in men over 40 years, with prevalence increasing with age. In this study, all participants with leukoplakia were above 50 years of age and were predominantly male. A significant reduction in lesion size and shape were observed postintervention. This could be attributed by fenugreek’s saponins and proteins with antioxidant and anticancer properties, promoting apoptotic cell death and preventing malignant transformation. The OLP was found to be mostly affecting middle-aged women, which was in accordance with previous studies. It showed no significant reduction in erythema or burning sensation postintervention, indicating a need for more extensive studies to fully evaluate fenugreek’s effectiveness on this condition. It is evident from few studies that flavonoids possess anti-inflammatory action that helps reduce the severity of the lesion.⁵⁰

In this study, fenugreek as an adjuvant significantly reduced burning sensation, mouth opening, and cheek flexibility in OSMF within groups during follow-ups predominantly in males. These findings suggest the potential benefits of fenugreek in managing OSMF, likely due to its anti-inflammatory and antinociceptive properties, anticarcinogenic activity exhibited by diosgenin via reduction of peroxidation reaction and marker enzymes.⁴² Also, this regression of symptoms could have been due to the anti-inflammatory and antinociceptive activity of alkaloid and flavonoid fractions of fenugreek seeds as well as due to the antioxidant effect exerted by fenugreek seeds, which is evident through its action in inhibiting superoxide generation and preventing tumor promotion.^5,51,52 However, no significant intergroup differences were noted, highlighting the need for longer follow-ups to determine efficacy.

The study observed good compliance with the fenugreek treatment and no attrition, indicating good participant engagement and adherence to the trial protocol. Thus, the study highlighted that fenugreek could be used as an adjuvant for managing OPMDs. The strengths of the present study were that the noninvasive, simple, and economical nature of the intervention along with its easy availability, accessibility, affordability, and acceptance by the community led to high cooperation and compliance from the subjects. However, the study’s follow-up duration was only 2 months, insufficient for observing complete regression of lesions that often have a lengthy clinical course. Recruitment during the COVID-19 pandemic’s second wave limited the sample size, affecting the generalizability of the results. The effective dose of fenugreek was not specifically calculated. Also, the effect of fenugreek on different grades/stages of OPMD’s were not specifically studied in the present trial. Hence, future research should explore fenugreek as a therapeutic agent, with well-controlled clinical trials featuring larger samples, emphasizing on different stages/grades of the lesion with longer follow-ups to fully establish its effectiveness in managing OPMDs.

CONCLUSION

The OPMDs can lead to oral cancer, necessitating early intervention. Fenugreek, known for its anticancer, anti-inflammatory, antioxidant, and antiulcerative properties, was used as an adjuvant in this study. It was found to reduce lesion severity in OSMF, showing significant progress during follow-ups. However, its effects were limited in leukoplakia and oral lichen planus cases. While fenugreek appears to be an adjuvant, more extensive clinical trials are necessary to understand its full potential and mechanisms in managing these disorders.

ORCID

Nandhini Balasundaram https://orcid.org/0000-0003-3839-2399

Aswath Narayanan MB https://orcid.org/0000-0002-5195-0132

Leena Selvamary Arul Antony https://orcid.org/0000-0003-4404-1843

Ramesh Kumar SG https://orcid.org/0000-0002-1215-6198

Sujatha Anandan https://orcid.org/0000-0002-5876-5458

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