Effectiveness of Oxitard Gel Versus Physiotherapeutic and Pharmacological Interventions in Alleviating Oral Submucous Fibrosis: A Phase-II Randomized Control Trial

Effectiveness of Oxitard Gel Versus Physiotherapeutic and Pharmacological Interventions in Alleviating Oral Submucous Fibrosis: A Phase II Randomized Control Trial

1. Introduction Oral Submucous Fibrosis (OSMF) is a potentially malignant condition that can take a debilitating turn if it is not managed in due course. It is a chronic, insidious and disabling disease of the oral mucosa. It is characterised by progressively restricted mouth opening, reduced tongue protrusion with depapillation of the tongue, fibrosis of the submucosal tissues, blanching and loss of elasticity of the oral mucosa, and a shrunken uvula (1). As the disease advances, these changes interfere with the most basic oral functions, including eating, speaking, swallowing and maintaining oral hygiene. The sites most frequently involved in OSMF are the buccal mucosa, the palate and the retromolar region. These are followed by the faucial pillars and the pharynx (2). Involvement of the soft palate and the faucial pillars can affect speech and swallowing. Involvement of the buccal mucosa produces the vertical fibrotic bands that are the classic clinical sign of the disease, and that progressively limit both mouth opening and cheek flexibility. 1.1 Epidemiology OSMF is most prevalent in South Asian countries. It is especially common in India, Bangladesh, Sri Lanka, Pakistan and Nepal. It is also reported from Taiwan, China and the Pacific Islands, with sporadic cases among other Asian populations (25). Its geographical distribution closely follows the cultural practice of chewing areca nut and its commercial products. Migration of South Asian communities has also led to cases being reported in other parts of the world. In Pakistan, and particularly in a large urban centre such as Karachi, the easy availability and low cost of areca nut products make OSMF a significant and growing public health concern. 1.2 Aetiology The literature shows that chewing areca nut is the most prevalent cause of OSMF. However, the disease is multifactorial. Iron deficiency, vitamin B12 and folate deficiency, and capsaicin (the active component of chilli peppers) may all play an important role in its progression (4). Nutritional deficiencies are thought to impair the repair capacity of the oral mucosa, making it more vulnerable to the irritants it is repeatedly exposed to. The sudden increase in commercially available modifications of areca nut, namely gutka, pan masala and mawa, also plays a pivotal role in the development of OSMF (1). These products are cheap, attractively packaged and easy to carry. Their use has spread to younger age groups, which helps explain why OSMF is now increasingly seen in adolescents and young adults. 1.3 Classification Numerous classification systems are routinely used for the clinical, functional and histopathological staging of OSMF. One of the most commonly used systems was introduced by Haider et al. In this system, clinical staging is based on the location of fibrotic bands, and functional staging is based on the range of mouth opening (7). This classification is simple to apply at the chairside, requires no special equipment beyond a measuring instrument, and directly relates the disease stage to the patient's functional limitation. For these reasons it has been adopted for the present study. 1.4 Pathogenesis While the functional classification gives a clear indication of the manifestations of OSMF, the root cause of these manifestations lies in the juxta-epithelial inflammatory reaction caused by soluble irritants present in areca nut and chillies (8). A burning sensation is the first sign of inflammation. This is followed by the formation of vesicles, which leads to ulceration of the oral mucosa (8). The normal epithelium is gradually replaced by an atrophic epithelium with reduced vascularity. This leads to defective healing and scar formation (8). The combination of these factors encourages fibrosis, which can be called the hallmark feature of OSMF. Fibrosis in turn leads to restricted mouth opening, reduced tongue protrusion and reduced cheek flexibility (8). Because the process is progressive and largely irreversible once dense fibrosis is established, early intervention is essential to preserve function and to reduce the risk of malignant change. 1.5 Current management Over the years, various treatment modalities have been used for OSMF. The very first step when a patient is diagnosed is habit control. This means immediate cessation of the consumption of betel nut and of products involving pan, tobacco and betel nut chewing. Without habit cessation, no other treatment can be expected to produce lasting benefit. For patients in the early or intermediate stages, a non-surgical approach is preferred. These patients are encouraged to perform mouth opening exercises, including exercises with devices made from acrylic plates. Oral physiotherapy does help to improve mouth opening, but it is usually given as an adjunctive therapy rather than as a stand-alone treatment. Medical therapy, including vitamins, antioxidants and anti-inflammatory agents, is commonly combined with physiotherapy. 1.6 Purpose of the study The mainstay of this study is to test non-invasive contemporary and conventional approaches to improve the declining quality of life that comes with the various manifestations of OSMF. The study compares conventional treatment, consisting of mouth opening exercises and multivitamin therapy, with contemporary treatment, consisting of a novel topical herbal gel and a novel intraoral physiotherapy device called Shekar's appliance. All four treatment combinations are non-invasive, affordable and suitable for use by the patient at home.
2. Operational Definitions 2.1 Oral Submucous Fibrosis Oral Submucous Fibrosis is an insidious disease that may affect the entire oral cavity and can also extend to the pharynx (7). OSMF can be classified in various ways. Haider et al. differentiated presenting patients both clinically and functionally, in order to distinguish between the various levels of disease progression (7). For this study, a patient is considered to have OSMF when the diagnosis has been made in the Department of Oral Medicine on the basis of history and clinical examination, including palpable fibrotic bands, blanching of the mucosa and restricted mouth opening. 2.2 Clinical staging (Haider et al.) Clinical staging is based on the presence and location of fibrotic bands in the oral cavity (7). Clinical stage Fibrotic bands present Stage 1 Faucial bands only Stage 2 Faucial and buccal bands Stage 3 Faucial, buccal and labial bands 2.3 Functional staging (Haider et al.) Functional staging is based on the measurement of interincisal mouth opening (7). Functional stage Mouth opening Stage A 20 mm or more Stage B 11-19 mm Stage C 10 mm or less 2.4 Outcome variables

• Mouth opening: the maximum interincisal distance, in millimetres, between the incisal edges of the upper and lower central incisors, measured with a vernier caliper (4).
• Burning sensation: the patient's self-reported intensity of burning, recorded on a 10-point Visual Analogue Scale (VAS), where 0 means no burning and 10 means the worst burning imaginable (4).
• Cheek flexibility: the difference, in millimetres, between the distance from the angle of the mouth (V1) to a point one-third of the way along a line from the angle of the mouth to the tragus of the ear (V2), measured first at rest and then with the cheeks blown out (4).
• Tongue protrusion: the distance, in millimetres, from the incisal edges of the lower anterior teeth to the tip of the protruded tongue, measured from the lateral aspect (4).
• Mucosal colour and blanching: the appearance of the oral mucosa, recorded by standardised digital photographs and compared visually between visits.
• Conventional treatment: oral physiotherapy exercises and/or oral multivitamin therapy (Pentovit H).
• Contemporary treatment: the novel topical herbal gel and/or Shekar's intraoral physiotherapy appliance.
• Compliance: adherence to the allotted regimen, as recorded by the patient on the study record sheet.

1. Literature Review 3.1 Nature and malignant potential of OSMF OSMF is a debilitating chronic disease characterised by inflammation. It leads to progressive fibrosis of the submucosal tissues, resulting in rigidity and limited mouth opening, and thereby negatively affects the patient's quality of life (1). OSMF is a precancerous condition with one of the highest potentials among oral potentially malignant disorders to turn malignant, at around 7-13% (2). This makes early diagnosis, habit cessation and regular follow-up essential, not only for restoring function but also for the timely detection of malignant change. OSMF is most commonly seen in South Asian countries. It occurs across a wide age range, most commonly between 16 and 35 years, although it has been reported in children as young as five years (1, 3). Its occurrence in young people means that the disease often affects individuals during their most productive years, with consequences for their nutrition, social life and ability to work. 3.2 Classification and staging The most widely used classification for the clinical and functional diagnosis and staging of OSMF is the one developed by Haider et al. According to this classification, a patient presenting with faucial bands only is considered clinical Stage 1. A patient with faucial and buccal bands is classified as clinical Stage 2. A patient with faucial, buccal and labial bands together is regarded as clinical Stage 3 (7). The functional staging of OSMF is based on the range of mouth opening. Stage A is for patients with a mouth opening of 20 mm or more. Stage B is for patients with a mouth opening of 11-19 mm. Stage C is for patients with a mouth opening of 10 mm or less (7). Taken together, the clinical and functional stages help the clinician choose an appropriate treatment and monitor the patient's response over time. 3.3 General principles of management When a patient is diagnosed with OSMF, the first step is cessation of the habit, effective immediately. The treatment of OSMF then correlates with the clinical and functional stage of the disease. There has never been a standardised treatment protocol that dentists all over the world follow after diagnosing OSMF. Physiotherapy has evolved to become the primary treatment offered to patients. For the most part, OSMF is managed symptomatically and empirically (26). This lack of a standard protocol is one of the main reasons why comparative clinical trials of different treatment modalities are needed. 3.4 Physiotherapy Treatment for patients diagnosed with Stage 1, or mild, OSMF relies heavily on physiotherapy with regular check-ups (31). These patients are asked to perform various mouth opening exercises. These include the tongue blade exercise, tongue-in-cheek push, side tongue stretch, cheek puff, pucker, the "O" exercise, lip hold, and the up-and-down tongue stretch, used as an adjunct to other treatments to improve mouth opening (27). Physiotherapy works by repeatedly stretching the fibrotic tissue and the muscles of mastication, which helps to maintain and gradually improve the range of movement. The main limitation of physiotherapy is that it depends heavily on patient motivation and compliance. Exercises must be performed several times a day over months, and many patients stop once the initial discomfort sets in or when improvement is slow. Intraoral appliances, such as Shekar's appliance, have been developed to make physiotherapy more effective, more standardised and easier for patients to perform. 3.5 Pharmacological treatment Apart from physiotherapy, pharmacological treatment modalities include anti-inflammatory drugs such as corticosteroids, vitamins, micronutrients, and antifibrotic agents such as HMG-CoA reductase inhibitors (26). Intralesional injectables, including dexamethasone, triamcinolone and hyaluronidase, have also been used. Multivitamin and micronutrient supplementation is widely prescribed because nutritional deficiencies are believed to contribute to the progression of the disease. 3.6 Ayurvedic and herbal treatment Ayurvedic medicine has played a large part in the treatment of OSMF and offers a more holistic approach. Oxitard, an Ayurvedic medicine containing various herbal extracts, has been shown to be effective in improving mouth opening and burning sensation (28). A study conducted by Patil S. et al. showed significant improvement in mouth opening, burning sensation, tongue protrusion, pain associated with the lesion, and difficulty in swallowing and speech in patients treated with Oxitard capsules (28). Many studies have also used lycopene to treat OSMF. Lycopene is an antioxidant that works by scavenging free radicals and suppressing them physically and chemically (29). This protects cells from damage caused by highly reactive oxygen species (29). Herbal extracts have also been widely tested in patients with OSMF. These include aloe vera, curcumin, turmeric and tulsi. Studies have shown that after application of aloe vera gel, there was a change in collagen content (23). It is a simple and safe treatment modality when combined with cessation of the habit (23). Curcumin is a natural anti-inflammatory compound that disrupts the cell cycle and impedes the proliferation of cells (23). It also decreases connective tissue growth factor, which is associated with both the onset and the progression of OSMF (23). 3.7 Intralesional injections Patients diagnosed with clinical Stage 2, or moderate, OSMF are commonly treated with injectables, and a combination of corticosteroids and hyaluronidase has been used (31). Injections of placental extract, colloidal iodine, interferon-gamma and micronutrients have also been reported (31). While injections can produce measurable improvement, they are painful, require repeated clinic visits, and carry a risk of local complications. This makes them less acceptable to many patients. 3.8 Surgical treatment The most severe cases, clinical Stage 3 OSMF, are usually treated surgically (31). The simplest surgical procedure is primary excision of the fibrous bands (31). Other operations include coronoidotomy, coronoidectomy, and use of the buccal pad of fat as a graft to cover the intraoral defects (31). Other surgical options include collagen membrane, split skin graft, tongue flaps, nasolabial flaps, and an oral stent to prevent secondary scarring and relapse (31). Surgery is invasive, costly and requires hospital admission, and relapse due to fresh scar formation remains a recognised problem. 3.9 Newer modalities Recent developments have led to the use of Electroson (an ultrasound device), laser therapy and cryotherapy as treatment modalities. Vijayakumar M. et al. conducted a study in which all patients were treated with ultrasound together with intraoral manual kneading of the buccal area, to stretch the fibrotic bands within the limits of the patient's pain tolerance (30). Cryotherapy was given both before and after treatment for 5-7 minutes (30, 32). These approaches are promising, but they require specialised equipment and are not widely available in low-resource settings. 3.10 Gap in the literature The treatment modalities described above are well established. However, most of them are invasive, and physiotherapy is the only treatment that is truly patient-friendly. All the other interventions also carry a high cost. What is needed now is a non-invasive intervention that is both patient-friendly and cost-effective. This study addresses that need by combining known herbal extracts into a single gel formulation that patients can easily apply themselves and can afford. It also evaluates a new physiotherapy appliance, and directly compares both against conventional treatment within the same randomised trial.
2. Rationale There are various treatment modalities for OSMF, but there is no agreed treatment protocol. The management of OSMF depends on its clinical and functional stage (33). Many patients would rather accept a compromised quality of life than go through invasive procedures such as repeated intralesional injections or surgery. As a result, a large proportion of patients either delay treatment or abandon it altogether, allowing the disease to progress. The present study therefore uses only non-invasive treatment modalities. These are conventional mouth opening exercises and multivitamin therapy, and the contemporary novel herbal gel and novel physiotherapy device called Shekar's appliance. All four can be used by the patient at home and require no special clinical procedure beyond initial instruction and periodic review. The literature has shown that herbal medicines have profound effects in patients with OSMF (33). Herbal medicines including lycopene, vitamin E, aloe vera, cumin, curcumin and tulsi are rich in antioxidants. Antioxidants act by isolating free oxygen radicals from susceptible molecules (35). They provide an alternative pathway by competing with oxygen molecules, and help repair the damage caused by free radicals (35). Oxidative stress generated by areca nut constituents is thought to contribute to the inflammation and fibrosis seen in OSMF. A topical preparation that delivers several antioxidants directly to the affected mucosa may therefore reduce both symptoms and disease progression. The gel used in this study contains several components that reduce oxidative stress. Combining them in a single topical formulation may produce a greater effect than any single agent alone. This supports the view that antioxidants play an essential role in reducing the manifestations of OSMF, and the study may also add to the literature on future medications for the disease. Shekar's appliance offers a standardised way to perform oral physiotherapy. Compared with conventional exercises using wooden sticks, an appliance may provide more controlled and consistent stretching, and may be easier for patients to use regularly. Comparing it directly with conventional exercises will show whether this advantage translates into better clinical results. Finally, the interventions in this study are cost-effective, easy to dispense and non-invasive. They also lack any noticeable side effects (33). If they prove effective, they could be adopted widely, particularly in low-resource settings such as public sector dental hospitals in Pakistan, where the burden of OSMF is high and access to advanced treatment is limited.
3. Aim, Objectives and Hypotheses 5.1 Aim The aim of this study is to compare conventional treatment modalities, namely exercises and multivitamin therapy, with contemporary treatment modalities, namely a novel herbal gel and an intraoral appliance called Shekar's appliance, for the management of patients with OSMF.

5.2 Objectives

1. To assess sociodemographic parameters and clinical symptoms, including mouth opening, burning sensation, cheek extensibility, fibrotic bands and colour of the mucosa, for the categorisation of OSMF patients.
2. To determine the efficacy of a novel herbal gel, with active ingredients including Nigella sativa, tulsi, curcumin, aloe vera, lycopene and vitamin E, in reducing the severity of OSMF.
3. To determine the efficacy of a new intraoral appliance, Shekar's appliance, in reducing the severity of OSMF.
4. To compare the efficacy of the novel herbal gel and the novel intraoral appliance with traditional treatment modalities (stick exercise and multivitamin therapy), to see whether one or both are better than conventional modalities for the treatment of OSMF.

5.3 Hypotheses

• Null hypothesis (H0): There is no difference between conventional and contemporary treatment modalities in the improvement of mouth opening, burning sensation, cheek flexibility, tongue protrusion and mucosal colour in patients with OSMF.
• Alternate hypothesis (H1): There is a significant difference between conventional and contemporary treatment modalities in the improvement of mouth opening, burning sensation, cheek flexibility, tongue protrusion and mucosal colour in patients with OSMF.

1. Materials and Methods 6.1 Study design This is a randomised controlled trial, conducted as a pilot study. A pilot design has been chosen because the herbal gel is a novel formulation and Shekar's appliance has not previously been evaluated in this population. The pilot will provide preliminary data on efficacy, feasibility, patient compliance and acceptability, which can then be used to plan a larger definitive trial.

6.2 Study site The study will be conducted in the Department of Oral Medicine, Dow International Dental College (DIDC), Dow University of Health Sciences (DUHS), Karachi, Pakistan.

6.3 Study population The study population will consist of patients diagnosed with OSMF in the Department of Oral Medicine of Dow International Dental College Hospital and Dr. Ishrat-ul-Ibad Khan Institute of Oral Health Sciences, Karachi. Both institutions receive a large number of patients from across Karachi and neighbouring areas, including many with areca nut and gutka chewing habits.

6.4 Inclusion criteria

1. Patients diagnosed with OSMF who present with the complaint of limited mouth opening, burning sensation, fibrotic bands and blanched mucosa.
2. Patients who fall under Haider et al. Clinical Stage 1 or 2 and Functional Stage A or B.

6.5 Exclusion criteria

1. Patients with OSMF who have a leukoplakic, erythroplakic or speckled appearance, or non-healing ulcers, or who are suspected of malignancy on clinical examination or biopsy.
2. Patients with any temporomandibular joint (TMJ) dysfunction.
3. Patients with psychiatric disorders.
4. Patients presenting with other oral lesions that cause a burning sensation, such as aphthous stomatitis, burning mouth syndrome and vesiculobullous diseases.
5. Patients with hypersensitivity to any component of the gel or to any vitamin. These criteria ensure that improvement in the outcome measures can be attributed to the study interventions. Patients with suspected malignancy are excluded so that they can be referred immediately for appropriate investigation and management. Patients with TMJ dysfunction are excluded because joint pathology can itself limit mouth opening. Patients with other burning lesions are excluded because these would confound the assessment of burning sensation.

6.6 Sampling technique Eligible patients will be recruited using non-probability consecutive sampling: every patient who meets the inclusion criteria and gives consent during the study period will be enrolled until the required sample size is reached. Enrolled participants will then be randomly allocated to the four study groups, as described in Section 7.3.

6.7 Sample size The sample size was calculated from the parent article using OpenEpi software, with a 95% confidence interval and 80% power (36). The calculated sample size is 5 participants in each group, giving a total of 20 participants across the four groups. Because the follow-up period is three months, some participants may be lost to follow-up. It is therefore advisable to recruit a small number of additional participants to allow for attrition.

6.8 Formulation of the novel herbal gel The gel is produced by Nutrimed Laboratories. Its active ingredients and excipients are listed below.

Component Concentration Active ingredients Nigella sativa 1% Tulsi 1% Aloe vera 1% Curcumin 1% Lycopene 1% Vitamin E 0.1% Carbomer 974P - Rheological (gelling) agent Humectant, stabiliser, preservative, pH adjuster, flavour - Excipients Water- Vehicle The gel base allows the active ingredients to remain in contact with the oral mucosa for a longer period. Patients will be instructed to apply a thin layer to the affected areas with a clean fingertip.

6.9 Shekar's appliance Shekar's appliance is a novel intraoral physiotherapy appliance designed to improve mouth opening in patients with OSMF. It is used to perform assisted oral physiotherapy, in which controlled stretching of the fibrotic tissues and the muscles of mastication is applied in a consistent and repeatable way. Each participant in Groups 3 and 4 will be shown how to insert, use and clean the appliance, and their technique will be checked at each follow-up visit.

6.10 Multivitamin therapy The multivitamin preparation used in this study is Pentovit H, taken orally. Multivitamin therapy is included in the conventional arm because nutritional deficiencies, including deficiencies of iron, vitamin B12 and folate, are believed to contribute to the progression of OSMF (4).

1. Data Collection Procedure 7.1 Ethical approval and informed consent Ethical approval will be obtained from the Institutional Review Board (IRB) of DUHS before the study begins. Each participant diagnosed with OSMF will be briefed about their condition, the nature and purpose of the study, the treatments involved, and the follow-up schedule, and will be invited to take part in the clinical trial. All participants who agree will be asked to sign a written informed consent form. The consent form will be available in both English and Urdu, and will be explained verbally to participants who cannot read.

7.2 History and clinical examination Each participant will complete a detailed history form covering personal, dental and medical history. This will include the type, frequency and duration of the areca nut, gutka, pan or tobacco habit. A detailed intraoral examination will then be performed by staff of the Department of Oral Medicine who are not part of the research team, so that the study members remain blinded to the identity of the study subjects.

The examination will record the following parameters:

• Mouth opening: the interincisal distance, measured with a vernier caliper between two fixed points, the incisal edges of the upper and lower central incisors (4).
• Burning sensation: evaluated using the Visual Analogue Scale (VAS) (4).
• Cheek flexibility: measured in millimetres between two fixed points, the angle of the mouth (V1) and a point one-third of the distance (V2) along a line connecting the angle of the mouth and the tragus of the ear (4). The first reading is taken with the participant at rest. The second is taken after the participant has been asked to blow out their cheeks. The difference between the two readings gives the cheek flexibility.
• Tongue protrusion: recorded in millimetres, as the distance from the incisal edges of the lower anterior teeth to the tip of the tongue, measured from the lateral aspect (4).
• Mucosal colour and blanching: recorded with digital photographs and compared by visual analysis. Photographs will be taken under standardised lighting and from the same positions at each visit, so that they can be compared reliably.
• Clinical and functional stage: recorded according to Haider et al. (7). Each participant will also be asked to provide a Complete Blood Count (CBC) report at the start of the study, to establish their baseline haematological status, including haemoglobin level.

7.3 Randomisation and allocation concealment Participants will be randomly allocated to four groups (Groups 1, 2, 3 and 4) using a computer-generated random sequence (simple randomisation). The sequence will be prepared by a faculty member of the Department of Oral Medicine (Person A) who is not otherwise involved in the study. The allocation of each participant will be carried out by a dental assistant, recorded on paper, and kept concealed until the results have been completed. Every effort will be made to prevent the research team from learning the characteristics of the study subjects.

7.4 Blinding Participants will not be told which intervention their study group is receiving. Outcome assessment will be carried out by Oral Medicine staff who are outside the research team and unaware of group allocation. The record sheets given to participants will not name the technique or medicine allotted to them. Because the interventions differ visibly (an appliance versus exercises, a gel versus tablets), complete blinding of participants cannot be guaranteed. Blinding of the outcome assessors is therefore the main safeguard against bias.

7.5 Intervention groups Group Physiotherapy component Medication component Group 1 (conventional) Physiotherapy exercises, 3 times daily, 30 minutes per session Pentovit H, twice daily after meals Group 2 Physiotherapy exercises, 3 times daily, 30 minutes per session Herbal gel, 3 times daily Group 3 Shekar's appliance, 3 times daily, 15 minutes per session Pentovit H, twice daily after meals Group 4 (contemporary) Shekar's appliance, 3 times daily, 15 minutes per session Herbal gel, 3 times daily Group 1: Participants will be advised to follow physiotherapy exercises (stick exercise, alphabet exercise, cheek pushing exercise, balloon blowing exercise, finger snap exercise, isometric exercise and hot pack massage) together with multivitamin therapy. Each participant will perform these exercises three times a day for thirty minutes per session. Each participant will take Pentovit H twice daily, in the morning and at night after meals.

Group 2: Participants will be advised to follow the same physiotherapy exercises together with application of the novel herbal gel. Each participant will perform the exercises three times a day for thirty minutes per session. Each participant will also apply the gel three times a day and will avoid eating or drinking for half an hour after each application.

Group 3: Participants will be advised to use the novel intraoral appliance, Shekar's appliance, together with multivitamin therapy. Each participant will use the appliance three times a day for 15 minutes per session. Each participant will take Pentovit H twice daily, in the morning and at night after meals.

Group 4: Participants will be advised to use Shekar's appliance together with application of the novel herbal gel. Each participant will use the appliance three times a day for 15 minutes per session. Each participant will also apply the gel three times a day and will avoid eating or drinking for half an hour after each application.

All participants, regardless of group, will be counselled at every visit to stop the areca nut, gutka, pan and tobacco habit completely.

7.6 Compliance Each participant will be given a record sheet on which to log their daily adherence to the allotted regimen. The record sheet will not name the technique or medicine allotted to the participant. The research team will review the record sheet at each visit, and participants who are not following the regimen will be counselled and encouraged.

7.7 Follow-up Each participant will be recalled every 15 days over a period of three months, giving a total of six follow-up visits per patient. At each recall visit, all the parameters described above will be measured again, and the record sheet will be reviewed to check compliance. At the final visit, at the end of three months, the parameters will be measured once more, a repeat CBC report will be obtained, and the record sheet will be collected. Any adverse effects reported by participants, such as irritation from the gel or discomfort from the appliance, will also be recorded at each visit.

1. Study Duration, Statistical Analysis and Ethical Considerations 8.1 Study duration The study will be completed within 9 to 12 months after ethical approval. This period includes recruitment of participants, the three-month treatment and follow-up period for each participant, and data analysis and write-up.

8.2 Statistical analysis The findings will be recorded in tabular form and analysed using the Statistical Package for the Social Sciences (SPSS). Descriptive statistics will be used to summarise the sociodemographic and clinical characteristics of the participants. Quantitative variables, such as