You are on page 1of 7

Babaee et al.

DARU Journal of Pharmaceutical Sciences 2013, 21:18


Antioxidant capacity of calendula officinalis flowers
extract and prevention of radiation induced
oropharyngeal mucositis in patients with head and
neck cancers: a randomized controlled clinical study
Neda Babaee1, Dariush Moslemi2*, Mohammad Khalilpour2, Fatemeh Vejdani2, Yasaman Moghadamnia3,
Ali Bijani4, Mahmoud Baradaran5, Mohammad Taghi Kazemi5, Asieh Khalilpour6, Mahdi Pouramir6
and Ali Akbar Moghadamnia5

This study was designed to determine the effect of Calendula officinalis flowers extract mouthwash as oral gel on
radiation-induced oropharyngeal mucositis (OM) in patients with head-and-neck cancer. Forty patients with neck and
head cancers under radiotherapy or concurrent chemoradiotherapy protocols were randomly assigned to receive
either 2% calendula extract mouthwash or placebo (20 patients in each group). Patients were treated with telecobalt
radiotherapy at conventional fractionation (200 cGy/fraction, five fractions weekly, 30–35 fractions within 4–7 weeks).
The oropharyngeal mucositis was evaluated by two clinical investigators (a radiation oncologist and a dentist), using
the oral mucositis assessment scale (OMAS). Trying to find out the possible mechanism of action of the treatment, total
antioxidant, polyphenol and flavonoid contents, and quercetin concentration of the mouth wash were measured.
Calendula mouthwash significantly decreased the intensity of OM compared to placebo at week 2 (score: 5.5 vs. 6.8,
p = 0.019), week 3 (score: 8.25 vs. 10.95, p < 0.0001) and week 6 (score: 11.4 vs. 13.35, p = 0.031). Total antioxidant,
polyphenol and flavonoid contents and quercetin concentration of the 2% extract were 2353.4 ± 56.5 μM, 313.40 ±
6.52 mg/g, 76.66 ± 23.24 mg/g, and 19.41 ± 4.34 mg/l, respectively. Calendula extract gel could be effective on
decreasing the intensity of radiotherapy- induced OM during the treatment and antioxidant capacity may be partly
responsible for the effect.
Keywords: Radiotherapy-induced oral mucositis, OMAS (oral mucositis assessment scale), Calendula officinalis,
Antioxidant capacity, Gel formulation

Introduction is defined as inflammation of oral mucosa, typically
One of the most commonly perturbing adverse effect of manifesting as atrophy, swelling, erythema and ulceration
radiotherapy (RT) in head and neck cancers is oropharyn- [4]. Up to this date, no approved standard intervention
geal mucositis (OM) which comprises the main dose limit- has been found for the prevention or treatment of
ing side effect [1]. The OM has been reported by patients radiotherapy-induced OM. Several strategies are being ac-
to be as the worst side effect of cancer radiotherapy [2,3]. tively investigated, which are based on the mechanistic
Triottie et al. stated that the incidence of radiotherapy interruption of one or more pathobiological pathways in-
induced OM in head and neck cancer patients is more volved in this condition [5]. A large number of treatments
than 80% [3]. The OM, as a result of cancer management, and strategies have been studied for OM such as, growth
factors, cytokines, antibiotics, anti-inflammatory agents,
* Correspondence:
cryotherapy, mucosal protectors [6,7] and traditional ther-
Division of Radiation Oncology, School of Medicine, Babol University of apy such as pure honey [8] and herbal medicines [9]. As an
Medical Sciences, Babol, Iran example, it has been shown that chamomile mouthwash, is
Full list of author information is available at the end of the article

© 2013 Babaee et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative
Commons Attribution License (, which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly cited.

patient’s refusal. Radiotherapy was implemented during Patient selection 30 to 35 sessions in 7 weeks period with an accumulative In this study forty patients (20 males and 20 females) with dose of 6000 to 7000 cGy. using the OMAS. Two parallel. To consider cancers radiotherapy. According to the This investigation was conducted as a placebo-controlled mentioned properties for calendula officinalis such as clinical trial. lips. The protocol was approved by Ethics Commit- anti-inflammatory. re- target volume received at least 6000 cGy total radiation spectively [15]. Iran and and considering the pathobiology of OM. vitis or oral ulcer] and concurrent medications. etc. A boost in dose of 1600–2400 cGy was (a radiation oncologist and a dentist). DARU Journal of Pharmaceutical Sciences 2013. Scale (OMAS) scores.). antifungal. The spinal cord dose was restricted to Oropharyngeal mucositis was evaluated by two physicians be <4600 cGy. Also to ensure reli- able outcomes. gone (no less than one third of the oral cavity) in the pri- Calendula officinalis.Babaee et al. upper and lower tients treated concurrent radiotherapy and chemotherapy. of either calendula or placebo (20 patients in calendula wash as gel formulation in the OM of head and neck group. comorbid disease (dia- cological activities which include antioxidant action. teresting to evaluate its effect on radiation-induced OM. Considering the treatment period of 7 weeks. probable gender effect. bacterial or fungal). and antiviral systemic infection. repeated every 3 weeks during treatment period. poor oral hy- properties [11]. active gingi- calendula officinalis was highly effective in the preven. hypertension. It was observed that this plant has cytotoxic effect on tumor cell lines in vitro Study design and anticancer activity in vivo [13]. left and right buccal with ID No: IRCT201106076734N1. The informed Based on these concepts. treatment sessions. each time 5 ml to be held for at of head and neck were randomly divided into two equal least one minute in oral cavity. They Erythema considered as: 0 point (no erythema). Drugs were ad- recruited. pa. antibacterial. and 20 patients in placebo group). It is a validated reliable semi quanti- formed consents were taken from the patients and they tative tissue injury scoring scale. avoiding spicy foods and inter-observer reproducibility [14]. The patients with proven squamous cell cancers ministered two times daily. floor of mouth. the extract of this plant possesses some pharma. with the entire of oropharynx 6 indices were provided for each patient. mary beam and Karnofsky Performance Status (KPS) >70 is used in the Western and Asian countries for its anti. dose (200 cGy-5 days/week). tion of acute dermatitis in patients with cancer undergo- ing postoperative irradiation [12]. had a same taste. Oral cavity is divided into 9 re- with a curative intent. The OM severity in all therapy or chemoradiotherapy were informed to take oral patients was measured using Oral Mucositis Assessment mouth wash calendula 5 ml b. 1 were treated using cobalt-60 at 80 cm SSD. This investigation was a groups either received calendula extract mouthwash or double blind study. betes mellitus. Patients receiving curative radio. point (mild to moderate erythema) and 2 points (severe opposed lateral fields and an anterior lower neck field erythema). Calendula and placebo mouthwashes placebo (control group). it would be in. it was registered in Iranian Registry of Clinical Trials (www.darujps. This scoring system and smoking. blocks were used individually in cases of need. left and right ventral and receiving cisplatin (100 mg/m2) with or without fairly effective on reducing post chemotherapy-induced and oral cavity at least 3 cm anterior to the retromolar tri- OM [9]. For ulcers as follows: 0 point (no ulcer). . radiotherapy. lateral tongue. Shielding Indices were taken weekly during the treatment period. consented patients were divided randomly into two groups termine the effect of calendula flowers extract mouth. shape and odor. given to residual disease at the primary site. gions: hard and soft palate. In. All regions of oral cavity had been assessed fluroracil (5-FU) on the first 3 days of the first week then for erythma and ulcer.we allocated 10 men and 10 women in both calendula and placebo groups. were the inclusion criteria. commonly known as Marigold. From the beginning of radiother- a diagnosis of head and neck cancers from Shahid-Rajaie apy. patients were given either placebo or 2% calendula radiotherapy center (Babolsar city. collagen vascular disease. irct. anti–inflammatory. was introduced by Sonis (15) as a simple method to accur- Patients received radiotherapy or chemoradiotherapy ately evaluate the mucositis. According to some re. the patients’ tumor sites were matched by a Methods radiation oncologist.i. 1 were used in daily treatment with a mid-plane radiation point (ulcer <1 cm). Northern Iran) were extract mouthwash as a gel formulation. this study was designed to de. Babol. Exclusion criteria included: history of head and neck ports. 2 points (ulcer 1–3 cm) and 3 dose of 200 cGy to a total of 6000 –7000 cGy in 30–35 points (ulcer >3 cm). Results of one clinical trial showed that giene [infection (viral. In chemoradiotherapy groups. inflammatory properties [10]. and antioxidant effects tee of Babol University of Medical Sciences. Planning The maximum and minimum scores were 45 and 0.d (12 hours interval). with demonstrated intra were instructed for oral hygiene care. cardiac disease. anti bacterial. 21:18 Page 2 of 7 http://www.

50. which is a common reference tography System (Knauer. Faculty of Medicine. Data ac. the total phenol contents were assayed using prepared in methanol HPLC grade as a solvent and the colorimetry at 765 nm. compared to a blank. The filtrate was finally di- Carboxymethyl cellulose (CMC) (15 g). shape. 25.5 ml of 1:100 mg ml-1 methanolic extract) or gallic HPLC acid (phenolic standard compound) was mixed with the Quercetin (main flavonoid aglycon) standard was pur. MO. 100. reagent (5 ml. v/v). Babol University of Medical trations (20. 1%) 100°C. and mixed it till the concentration of antioxidant with a ferric reducing ability mixture became uniform.983) was cal. Germany) that consisted of a compound. 4.8 mL/min was used. 150. and Total phenols determination taste to calendula mouthwash. diluted and injected in five Mouthwash preparation containing 0. four-channel pump. Total antioxidant activity was estimated by a FRAP (ferric ume reached 800 ml. The analytes were detected by UV vided from local resources and it was identified and absorption at 290 nm. C18 H methanol. 1:10 diluted with distilled water) and chased from Sigma Chemical Co. to which a 20 μl sample loop was attached. then methyl and prophylparaben reducing antioxidant power) assay [16].4. The standard curve of quercetin authenticated by herbal section of Department of Pharma. Total chromatographic purposes were of HPLC grade. 0. The vehicle as the base of mouthwash was prepared as follows: first CMC was dissolved in about 250 ml distilled water. dula mouthwash. the mixture was left at room temperature for 30 min. In order to prepare the ve.2 g). The alcohol concentra. A dilute solution of the extract (0. The mobile 6. gallic acid equivalent. A purification system (HastaranTeb Co. All solvents used for of gallic acid in methanol:water (50:50. HPLC phenolic contents were shown as mg/g (of dry mass) of was performed using a Knauer Smartline Liquid Chroma. The standard curve was obtained linearity of peaks area to concentration (r = 0. 0. Then length. Five different con- were dissolved in glycerin in a temperature of 70 to centrations of the calendula extracts (0. using Whatman filter. Iran and a voucher specimen (No: injection was 20 μl.6 mm in diameter and 250 mm in 1 M potassium acetate and 2. (St. UV/VIS detector and an injection valve. Babol. Principle of this method is based was added to them.8 ml of distilled water. 0. Different quercetin solutions at concentrations single-column isocratic reverse-phase method. 2 and 1 μgml-1). After the prepar. Afterwards 100 ml of primary gel (CMC + DW) were used for this test. 250 and 500 mg l-1 solutions culated using regression analysis. using 0. hicle of the mouthwash we used following ingredients: 2-μm pore. 0. 10 ml of ethanol in 95° on the reduction of a ferric-tripyridyltriazine complex to was added. USA). equivalent to that of 1 mmol/l FeSO4 [17].5% orthophosphoric acid. 21:18 Page 3 of 7 http://www.darujps. methanol was extracted and filtered through a 13 mm.Babaee et al. Louis. ethanol tion was injected for HPLC analysis. Total flavonoids determination quisition and processing were performed on a personal Total flavonoid contents were determined using aluminum computer using Chromgate software. 1 M).5 ml of %1 extract) was mixed with 1. beam Jenway UV/Visible spectrophotometer (UK) and ation of mouthwash base. Reno. and then. 0. glycerin (25 ml). tion in the final solution was one percent. The placebo mouthwash is the mouth- wash base which has been matched in odor. Chromatographic analysis was carried out using a 415 nm. DARU Journal of Pharmaceutical Sciences 2013. colored form in the presence of antioxidants gel and remaining distilled was added to this mixture till and the absorbance was read at 593 nm with a single to reach a maximum volume 1000 ml. 25.2. Total phenolic contents were evaluated using Folin- Ciocalteu reagent [18]. (100 mg) with 6 ml 25% hydrochloric acid and 94 ml nol 70% for a 72 hour period. The column was a Prontosil #60-5.5 ml of Nevada. and distilled water. The present solution was mixed to primary its ferrous. the Tehran. The final result was expressed as the tract for a total volume of 1000 ml.1 ml of column that was 4. in order to provide 2% calen. .25. we added 20 g calendula ex. prophylparaben (0. A flow rate of Dry and pulverized calendula officinalis flowers were pro. After 15 min standby Standard stock solution of this aglycone (20 μml-1) was period. The volume for each Science. then Determination of total antioxidant activity distilled water was added gradually till the primarily vol. 0. CS_00236) was deposited. luted with methanol in the ratio 1:2 and 10 μl of this solu- methyl paraben (1. Each extract was 95o (10 ml). extract (0. 50 and 100 mg l-1 in methanol were pre- phase consisted of a 40:60 mixture of methanol and water pared to obtaining standard curve. 12. aqueous Na2CO3 (4 ml. was prepared using standard solutions of different concen- cology.5 g).USA).5. FNR12. Sample injections chloride colorimetric method [19].1. 10.5.1 ml of 10% aluminum chloride. Sample Preparation for HPLC analysis: The plant flowers Extract of Calendula was made by maceration in etha. Calendula methanolic were performed using a 100 μl syringe (Hamilton. Iran) was used for the filtration (deionization) of absorbance of the reaction mixture was measured at water.

007× + 0.0 Placebo Tumor location 6. ary metabolites such as polyphenols. tion (the standard curve equation: y =0. one-way ANOVA and repeated measures shown in Figure 3. None of the patients in calendula group underwent medica. OM inten.2.33).048).5. an extensive damage is seen to result in destruc- not show OM in the whole treatment period. and focused on pain control [21]. 0. .0 OMAS female 10 10 10. the mean ± SD of quercetin concentration in the terial counts which may increase over 300% compared to Table 1 Comparison of the patients’ individual results in among two treatment groups Treatment groups Placebo Calendula 20. 3 and 6 of the study and current clinical management of OM is mainly palliative (Figure 1).3 ± 381.0 ** Male 10 10 14. In the present study three pa- sity was measured according to OMAS scores at the end tients of calendula group didn’t demonstrate OM after of each week for both calendula and placebo groups.1. In addition. r = 0.1. *** p = 0. 0. Many beneficial activities reported for the (p < 0. Discussion tion for OM severity and radiotherapy was not ceased When biological changes induced by radiotherapy is being for this reason.8 and 2353.8 52.5. * p = 0.0 Calendula Nasopharynx 10 11 4. but in both and essential oils [22]. equation: y =0. radiotherapy in the whole treatment period. Quercetin concentration as a main fla. 1714. Mann–Whitney gerprint of hydroalcolic extract of calendula officinalis is U test. Several calendula therapeutic prop- group of genders calendula had better results compared to erties such as.998) was 76.three patients were exclude that had left the phenol using gallic acid concentration (the standard curve study.2 ± 305. six patients were excluded : Four concentrations (0. cartenoids.52 mg/g of gallic acid equivalent in the extract of calen- (Additional file 1). flowers extract based on quercetin equivalent concentra- sidered as the statistical significant difference.0 12.4 ± 56. In the calen. In calendula group three patients did initiated.34 mg/l (%RSD = 15.3337. Al. Statistical analysis was performed on 20 and18 pa.005× + 0. respectively.0 extract 18.031. no study has the differences between OMAS of calendula and placebo investigated the effect of calendula officinalis on radiation- during the weeks of evaluation were statistical significant induced OM. 21:18 Page 4 of 7 http://www.5. Up to date. The p values of less than 0.0 Tonsil 2 3 0 1 2 3 4 5 6 7 8 Time (week) Radiotherapy alone 4 3 Figure 1 Mean (±SEM) of OMAS scores changes by time (week) Chemoradiotherapy 16 17 in placebo and calendula treatment group.05 were con.24] placebo (Figure 2). triterpenes though OM intensity was higher in women.24 mg/g. anti-inflammatory. OMAS scores were significantly lower in calendula group Most interventions have been proven to be ineffective compared to placebo at week 2.darujps. 0.Babaee et al. 1877.001) and OM intensity was significantly decreased in plant are mainly related to the contents of various second- calendula compared to placebo group (p = 0.999) was 313. two patients had severe tracts were 565.3 ± 318. anti-tumorogenic [23. 54. According to repeated measures ANOVA test.0 * Mean age 52.5 ± 126. HPLC fin- Data were analyzed by using t-test.4. r = Statistical analysis extract was 19. 1059. have been reported. and 1%) of calendula ex- patients had left the study .001. tion of intact mucosa [20]. mucositis and treated with another drugs. Total 20 20 ** p < 0.5 μM.66 ± 23.40 ± tients in calendula and placebo groups respectively 6. According to the standard tivities of its oils have been proven [25]. Individual char- acteristics of the patients are detailed in Table 1. The flavonoid contents of calendula ANOVA tests.1 (range 46–72) completed the study.0001. DARU Journal of Pharmaceutical Sciences 2013.2 8.0 Parameters *** Number of patients 20 20 16. Regardless of bac- curve. Total dula group . 0. in vitro anti-microbial ac- vonoid content was measured. Results The FRAP results for ferric reducing ability in five In the pcacebo group .0 Oral Cavity 7 6 2.0 Salivary glands 1 .019. Thirty eight patients with mean age dula officinalis.41 ± 4.

LACE has immune- ent role in maximum protection against oxidative stress modulatory activities [5. It prevented or minimized by regimen-related injury [42]. compared to quercetin standard [Q.0 degenerative diseases. class of antioxidant agents which act as free radical termi- male nators [34. increasing gram negative bacteria that is seen dur. has been demonstrated that plant polyphenols such as fla.darujps.Babaee et al. antioxidant activity of the extract was confirmed. flow rate. for example heart disease. The flavonoids which contain hydroxyl extract (LACE).com/content/21/1/18 induced by high level of reactive oxygen species (ROS) in 20. rate-limiting step and by delaying or stopping it. hepatotoxicity. the flovonoid and phenolic phytochemicals in calendula officinalis and its antioxidant activity can support its high radical scavenging activity and following protective effect in radiotherapy.43]. detection at 290 nm.induced OM. it may vonoids are a most important active natural products act against ROS and prevents or delays the initiation phase. cell lines.0 Placebo. On the other hand. Initiation phase of radio- baseline. tumor promotion. The initiation phase is a dula has been reported [27]. In this study quercetin as a flavonoid with anti-inflammatory effect [39-41] has been assayed in 0. 0.0 Calendula. According to this study. 0. According to the present re.0 and cancer [36-38].0 0 1 2 3 4 5 6 7 8 the calendula flower extract and antioxidant capacity was Time (week) measured using FRAP test as well. step in the development of mucositis in which clonogenic ial proportions for spontaneous ulcer resolution [26].23. athero- sclerosis. the high contents of Figure 2 Mean (±SEM) of OMAS scores changes by sex and time (week) in placebo and calendula treatment group. The ROS play a causative role in several OMAS 10. 21:18 Page 5 of 7 http://www. phenolic compounds are a male 15. it can be sults. therapy or chemotherapy-induced injury is a critical first ing ulceration needs to be re-established by normal bacter. There is very few safety Figure 3 HPLC fingerprint obtained from hydroalcolic extract of calendula officinalis flowers (A). from 70 to 100% or chelating [31-33] effects. This effect is considerable In one study which evaluated laser activated calendula on human health. the most dominant components.5% aqueous solution of orthophosphpric acid (0. DARU Journal of Pharmaceutical Sciences 2013. Method characteristics: methanol (40%). cell death and the production of ROS by injured cells are Antioxidant activity and wound healing properties of calen. According to our investigation.6%). inflammation. 20 microgram/ml] (B). the LACE showed to be capable in vitro groups are responsible for the radical scavenging [28-30] inhibition of tumor cell proliferation. possessing antioxidant activity.8 ml/min. the body. Considering the antioxidant properties of calendula. These agents accompanying when tested on a wide variety of human and murine tumor with several endogenous antioxidants may play an promin.35]. 5. .

YM: antioxidant properties of calendula may be responsible for English writing and grammar correction. and it perhaps need to be 2. Carrie C. 21:18 Page 6 of 7 http://www. In other words. Akihisa T. Babol University of Medical Sciences. Barasch A: Oral mucositis. treatment of venous leg ulcers [47]. AB: statistical analysis.e. MK. Finally. Oral Oncol 2010. DM: physical exam and study design been suggested that anti-inflammatory. 16:655–660. 9:40–47. Takido M. breast cancer. However. Fuchs HJ. School of Medicine. antioxidant defense mechanism and granuloma it without any significant side effects (i. also allergic hypersensitivity may cause a problem for individuals sensitive to other members of the Competing interest plant family asteraceae [44]. Kuttan R: Effect of calendula officinalis flower extract on pletely prevent its occurance. School of tive irradiation [12]. . AAM: study design and manuscript mentioned effects on gingivitis [45]. 3. Lalla RV. alcohol may be questionable. It has been demon. among reviewed clinical trials the mentioned study was the closest one to our inves.darujps. it is concluded that calendula officinalis is ef. Trotti A. J Clin Diagn Res 2009. Sonis ST. MB: data collection. References wash could not completely prevent OM can be explained 1. Iran. be elucidated. School of Medicine. Peterson DE: Treatment of mucositis. Received: 21 January 2013 Accepted: 26 February 2013 Published: 7 March 2013 tigation. Epstein JB. Epstein J. induce injury to the oral mucosa. Phytochemistry 1996. Department of Pharmacology. 10. Babol University of skin from irritant contact dermatitis caused by exposure to Medical Sciences. Babol University of Medical Sciences. Although the chemotherapy: a systematic literature review.. It is also sug. different pathobiology profiles. Fey E. Babol University of Medical Sciences. FV: English writing. Motallebnejad M. Pouliot K. Komaroff E.Babaee et al. nausea and formation during thermal burns. 3:1537–1542. discussion 35–26. concentration of alcohol in final solution was lower than to 4. applied for a longer duration of time. dermatitis and OM have Medicine. Watkins B. 22:1447– concerns related to calendula. Rubenstein EB. AK: lab tests examiner. Kumaki K. And as earlier mentioned. It has been shown that calen. Ahmadi F. Lalla RV. Chandran PK. Omidi S: The is higher in females than males. Dent Clin North Am 2008. et al: Clinical practice guidelines for the prevention and treatment of cancer therapy-induced oral and gastrointestinal mucositis. with head and neck cancer receiving radiotherapy with or without alcohol containing mouthwash was used. menstruation. Schubert M. Gwede CK. even though different 2:21–32. antibacterial and and manuscript writing. women [49]. School of Dentistry. 43:58–64. Frame D. Kasahara Y. including new medications. systemic adminis. Shabanloei R. Tuthill C. can irritate the oral mucosa and it is effective in reducing 6. 11. Babol. Babol. Elting LS. Oral Dis 2010. Akram S. two genders. Babol. the duration of pain associated with oral mucositis induced Cancer J 2006. for the financial support. it has been demonstrated that its intensity 8. Additional file tration of calendula products should be avoided during early stages of pregnancy due to its ability to stimulate Additional file 1: CONSORT 2010 flow diagram. Peterson DE. It has NB: physical exam and study design. 43:1255–1260. (1996). their anti-inflammatory effects. gested using calendula preparations in high dose of in Cancer 2004. 52:61–77. Peterson DE: Management of oral mucositis in patients by chemotherapy (49). 100:2026–2046. McGuire D. showed positive preliminary The authors would like to thank department of research affairs of Babol results for the administration of calendula ointment in the University of Medical Sciences. Tehran. Sonis S: Attenuation of radiation. 7. All patients could tolerate acute phase proteins. Pommier P. Keefe D. Hajizadeh E. D’Hombres A. by the complicated pathobiology of OM. Duran et. et al: Alloprinol. Elad S. Babol. Iran. Oinuma H. severity and associated outcomes in patients factor when evaluating its effects. dula extract toothpaste could effectively reduce plaque and Authors’ contributions bleeding indexes in moderate to severe gingivitis. DARU Journal of Pharmaceutical Sciences 2013. J Contemp Dent Pract 2008. Sciences. it has been 5. Moghadamnia A. Yamanouchi S. 12:348–354. 66:253–262. All authors read and approved the final manuscript.and chemoradiation-induced mucositis using gamma-D-glutamyl-L- found that chlorhexidine mouthwash containing alcohol. On the other hand. Sunyach MP. Yasukawa K. 6Department of Biochemistry. Regarding to comparison of OM in who have cancer. it writing. J Support Oncol 2004. tryptophan (SCV-07). Although. MTK. order to be more effective. Raber-Durlacher JE. Iran. al. This may be due to physiological differences Dolatkhah R. 3School of Basic sodium lauryl sulfate [48]. The authors declare that they have no competing interests. Gomez F. has been reported calendula flowers extract as an ointment is effective in relieving pain of cracked or tender nipples Acknowledgements [46]. 5 dermatitis in patients with cancer undergoing postopera. chamomile and normal saline mouthwashes between two sexes but its exact mechanism remains to for the prevention of chemotehrapy-induced stomatitis. Iran. has been reported in 9. Author details 1 strated that calendula as a cream preparation protected Department of Oral diseases. the irritant effect of 46:452–456. In the present study. Severe stomatitises effect of topical application of pure honey on radiation-induced mucositis: a randomized clinical trial. J Clin Biochem Nutr 2008. Furhter investigations are recommended to 12. Bellm LA. Iran. Montbarbon X: Phase III randomized trial of calendula officinalis compared with elucidate the optimal dose and administration frequency trolamine for the prevention of acute dermatitis during irradiation for to have better outcomes in radiotherapy-induced OM. 2Division of Radiation Oncology. Vaez J. Ansarin K. et al: Triterpene alcohols from the flowers of compositae and fective on decreasing OM intensity but cannot com. Babol. The fact that calendula mouth. 4Non-Communicable Pediatric calendula was highly effective in the prevention of acute Disease Research Center. Radiother Oncol 2003. J Clin Oncol 2004. Javadzadeh Y. Moulana Z. and radiotherapy induced OM. Sonis ST: A biological approach to mucositis. Alzahra University. vomiting). Babol University of Medical Sciences. Generally there are few studies concerning effects of herbal extracts on OM. protocols for herbal extraction should be considered as a et al: Mucositis incidence. MP: biochemical analysis. Iran.

Mandel SA. Cite this article as: Babaee et al. Anal Biochem 1996. and pelargonidin inhibit only NF-kappaB chemotherapy. J Med Plant 2010. 46. J Pharm Pharmacol 2003. 73:2048–2053. C. Robards K: Phenolic content and Biochem Pharmacol 2008. Cohen HA. Sakao K. measure of “antioxidant power”: the FRAP assay. Brinker F: Herb contraindications and drug interactions. 3rd edition. Garrido F: A 1994. anti-inflammatory and antioxidant properties of 14. et al: Validation of a new scoring system for the assessment daidzein inhibit STAT-1 and NF-kappaB activations. Goity L. Kahan E: Naturopathic treatment for ear pain in preparations against sodium-lauryl-sulfate-induced irritant contact children. Ottaviani A. 111:e574–e579. Sloan JA. Symonds RP: Antimicrobial 49. 28:1387–1404. 38. Kroon PA. 60:516–520. Sumitomo K. Prenzler PD. 27. McKinley AJ. DARU Journal of Pharmaceutical Sciences 2013. Lancet Infect Dis 2003. differences in fluorouracil-induced stomatitis. Elsner P: Protective effects of marigold (calendula officinalis).chemistry. new extract of the plant calendula officinalis produces a dual in vitro 47. van der Vijgh WJ. Cancer 1999. Hou DX: Clarification of the role of quercetin hydroxyl groups in superoxide generation and cell apoptosis by chemical modification. iron-dependent and take full advantage of: oxidative stress and PKC signaling pathway. Siegers CP: Inhibitory action of some flavonoids on enhanced spontaneous lipid peroxidation following glutathione depletion. Int J 24. Moghadamnia AA. Gueux E. 2001. Fitoterapia 2003. Cook NC. Sonis ST: New thoughts on the initiation of mucositis. Zhang C: Inflammation and reactive oxygen • Research which is freely available for redistribution species in cardiovascular disease. Loprinzi CL.biomedcentral. Theodoluz activity of calendula officinalis extracts. inflammatory effects of flavonoids: genistein. Poljacki M. Mucositis Study Group. Lopes NN. CAS. Kessler M. Int J Radiat Biol 2005. 32. 40. 21:18 Page 7 of 7 http://www. 2008:178–179. Tubaro A. Younes M. Kaufmann WK. Chimenti P. Apablaza C. Planta Med 23. Yoshimura EM. J Nutri Biochemist 1996. Negrete R. Sonis ST. Jo SK. Chang CC. Amoian MM. dermatitis. Paik SG: Factors effecting the Th2-like immune response Drug Analysis 2002. Antolovich M. Boucaud-Maitre Y. 26. Wen HM. Needs PW. Rock E. Sonis ST: Mucositis: the impact. Molecules 2007. Toxicol In Vitro 2001. 16:241–248. kaempferol. association between antioxidant and lipoxygenase inhibitory activity. Bast A: Flavonoids clinical study. metabolism. 116:263–269. Semin Reprod Endocrinol 1998. Modulation of cell survival genes. 18:195–200. activation along with their inhibitory effect on iNOS expression and NO 16. Decker Inc. 4:132–140. Vuorela P. Pharmazie 1988. 14:46–60. Avramovich-Tirosh Y. Zhang N. Nair S. Submit your manuscript at www. 18:412–420. Int J Vitam Nutr Res 2006. Benzie IF. Nieminen R. • Inclusion in PubMed. J Food Sci 2009. Maoka T. McDonald S. Haenen GR. Ontario: BC Buddleja globosa. 11th edition. Mediators Inflamm 2007. 45. Novotny PJ. Epstein JB. 43:220–221. van Acker FA. Yang MH. • Immediate publication on acceptance 36. 7:66–76. Kishimoto S. Park HR. Matic M. Jacobo-Velazquez DA. Reznichenko L. 69:2122–2128. 42. 76:22–27. Hamalainen M. as peroxynitrite scavengers: the role of the hydroxyl groups. 10:178–182. 73:73–84.: Antioxidant capacity of calendula 56:451–453. quercetin. Paules RS: Oxidative stress and cell cycle checkpoint function. oral mucositis. Boza P: effect: cytotoxic anti-tumor activity and lymphocyte activation. Oral Dis 2010. neutrophil infiltrate in 5-fluorouracil-induced oral mucositis in hamsters. Algernon O. antioxidant activity of olive extracts. Bizzarri B: Efficacy of Hypericum and calendula oils in the epithelial reconstruction doi:10. Backhouse N. Es-Safi NE. 45:1015–1020. DARU Journal of Pharmaceutical Sciences 2013 21:18. Schliemann-Willers S. Lalla RV. Fujii M. Fischer TW. 21. Mulagha MT. Busserolles J. World J Cardiol. J Ethnopharmacol 2008. Strain JJ: The ferric reducing ability of plasma (FRAP) as a production in activated macrophages. Barton DL: Sex therapy to prevent or treat oral mucositis. biology and therapeutic opportunities of presenting cells and small expression of the IL-12 receptor in T cells. 42:546–552. Biosci Biotechnol Biochem 2009. inflammatory activity of calendula officinialis [sic] flowers. 18. Results of the clinical examination of an ointment with marigold BMC Cancer 2006. 74:R107–R113. (calendula officinalis) extract in the treatment of venous leg ulcers. Paco L. Rayssiguier Y. Farmaco 2001. Garcia-Lora A. Scopus and Google Scholar 37. Greenberg M: Burket’s Oral medicine. Jovanovc M. 31. Jimenez-Medina E. Eilers JP. Amoian B. Mehrmanesh S: Lasers Surg Med 2010. Cisneros-Zevallos L: Correlations of antioxidant • Convenient online submission activity against phenolic content revisited: a new approach in data analysis for food and medicinal plants. of clinical trial research of oral mucositis induced by radiation or isorhamnetin. Ghidouche S. Chern JC: Estimation of total flavonoid 16:597–600. Baumann 13. Ubeaud G. and Peterson DE. Andresen BT. composition in petals of calendula (calendula officinalis L). 74:328–338. cardioprotective effects. Okuno S. Food Chemist 2001. Weinreb O. 3:405–412. Hogg N: Free radicals in disease. different marigold (calendula officinalis L. 44. Zheng H. Hamilton. Algarra I. whereas flavone. Sosa S: The role of triterpenoids in the topical anti- Biosci Biotechnol Biochem 2005. . J Food 43. Youdim MB: Multifunctional activities of green tea catechins in Submit your next manuscript to BioMed Central neuroprotection. Mazur A: Hodgson JM. Forg A. 17. Skin Pharmacol Physiol 2005.1186/2008-2231-21-18 of surgical wounds in childbirth with caesarean section. Epstein JB. 81:221–231. Buddlejaceae. after gamma-irradiation: low production of IL-12 heterodimer in antigen- 20. 33. 19. Samman S: Flavonoids . Moilanen E: Anti- 15. purification of the major anti-inflammatory triterpenoid esters from 48. The effect of calendula extract toothpaste on the plaque index and 22. 30. 85:2103–2113. Ohmiya A: Analysis of carotenoid bleeding in gingivitis. Sonis ST. Lavagna SM. Jung L: Anti. Pediatrics 2003. 6:119. Free Radic Biol Med 2000. et al: Analgesic. Collado A. 239:70–76. Raynaud J: Cytotoxic and antitumoral 39. 15:3–6. Bonsignore L. Balasinska B. Neurosignals 2005. Bellm LA. 34. Oral Oncol 2009. Loggia D.Babaee et al. officinalis flowers extract and prevention of radiation induced oropharyngeal mucositis in patients with head and neck cancers: a randomized controlled 28. 12:2228–2258. Heinonen M.and pro-oxidant activity of rutin and quercetin derivatives. Fuchs SM. 27:101–106. Hamburger M. Planta Med 1981. Eclectic Alves MT: Effects of low-level laser therapy on collagen expression and Medical Publications: Sandy. LeVeque FG. Ducrot PH: Flavonoids: hemisynthesis. et al: Metabolic transformation has a profound effect on In vivo antioxidant activity of procyanidin-rich extracts from grape seed anti-inflammatory activity of flavonoids such as quercetin: lack of and pine (pinus maritima) bark in rats. da Silva MA. Piriou Y. • No space constraints or color figure charges characterization and free radical scavenging activity. reactivity. and dietary sources. Weinreich B: Preparative Tissue React 2005. Gajinov Z. Duran V. 29. 55:131–142. Sarrell EM.darujps. 2:408–410. Stewart S. J Clin Oncol 2000. content in propolis by two complementary colorimetric methods. • Thorough peer review 35. Liggett WH Jr. Amit T. Donnelly JP. 43:240–244. Chavantes MC. Secci D. Plapler H. Shackelford RE. 75:1045–1053. Heijnen CG. Mimica N. Rosales L. Loke WM. Adler S.) and rosemary cream 25. Mazandarani M. Erazo S. 2007:45673. Proudfoot JM. 41.