Propolis is a resinousmixture that is collected by honey bees from tree buds, sap (ow, and other botanical sources. Propolis has beenextensively used in medicine, dentistry, and cosmetics; however, unwanted e)ects have been reported.'is paper reports a case oforal mucosal burn in a %#-year-old patient, who used an overnight application of concentrated propolis to overcome a throbbingpain in the right upper posterior mucosa.'e patient was otherwise healthy and was not receiving any medication. She presentedwith painful shallowmultiple irregular ulcersmeasuring #.*–! cm in diameter that were located on the right buccalmucosa and hardpalate mucosa, in addition to the gingival mucosa surrounding tooth !+. Propolis-induced oral mucosal burn was diagnosed.'eulcer cleared a,er the prescription of tetracycline mouthwash, accompanied with Doloneurobion.'e patient was further treatedwith carbamazepine to address the persistent throbbing pain in the a)ected area, which was suspected to be trigeminal neuralgia.'is report provides another alert to clinicians about the potential adverse e)ects of propolis use for the treatment of oral diseases,despite its natural origin.
1. Introduction
Propolis is a Greek word that literally means “in front ofthe city,” and it is sometimes referred to as bee glue. It iscollected by honey bees to construct their hives and servesas waterproof and protection material against invaders [!].'e chemical analysis of propolis has revealed at least *##compounds as its constituents ["]. It is a complex mixturecontaining resinous and balsamic compounds (%%%) as itsmajor constituents.'e remaining constituents are beeswax(*#%), essential oils (!#%), bee pollen (%%), and organiccompounds (%%; phenolic, esters, and (avonoids) [*].'esecomponents are collected from tree buds, sap (ow, andother botanical sources. 'e location of plants, climate,and environmental conditions have an important role indetermining the ratio and concentration of the componentsof propolis [!, $].
For many years, propolis has been considered as atraditional herbal medicine that heals various diseases [%].Propolis has been extensively used inmedicine, dentistry, andcosmetics. In vitro and in vivo animal studies of propolis have
inferred a number of its biological activities. For example, itexhibits astringent, antiseptic, anesthetic, anti-in(ammatory,antibiotic, antifungal, antiviral, antioxidant, immunomodu-lator, and antineoplastic activities [%–-]. However, clinicalstudies of propolis for oral diseases in humans remain limited[&–!!]. Despite the bene.ts of using propolis in medicine anddentistry, allergic reactions due to propolis have also beenreported [!", !*]. A recent study described "" cases of orallesions induced by the use of propolis, indicating that theimproper use of propolis may have serious adverse e)ects onthe oral mucosa [!$].
Although several published reports have describedadverse reactions to propolis [!", !*], we recently documenteda new case related to its use.Here, we report a case of awomanwho developed oral mucosal ulcers a,er the topical use ofconcentrated propolis on a painful dental area.
2. Case Presentation
A %#-year-old female patient was referred to the OralMedicine Clinic, Faculty of Dentistry, Universitas Indonesia,
F/0123 !: Shallow multiple irregular ulcers ranging from #.* to !.% cm in diameter with erythematous border, located on the right buccalmucosa, palatal mucosa, and gingival mucosa surrounding tooth !+.
complaining of a painful lesion located on her upper rightbuccal mucosa, in addition to the palatal mucosa. She hadexperienced throbbing pain in the mucosal tissue aroundtooth !+ a few days earlier. She reported the self-application ofa cotton roll that had been damped in propolis to relieve thepain in the mucosal area.'e cotton roll was le, in contactwith the mucosa overnight. She noticed the eruption of apainful oral lesion the next morning, which caused di4cultyin eating. 'e eruption of the lesion was not accompaniedby any systemic symptoms, and no other body areas wereinvolved. She also reported the daily consumption of propolisdiluted in her drinking water. A review of her medicalhistory revealed an allergic history to chloramphenicol andoccasional gastric pain. Otherwise, the patient was healthyand was not under any medication. A clinical examinationrevealed multiple shallow and irregular ulcerations on theright buccal mucosa, the right hard palate mucosa, and thegingival area surrounding tooth !+. 'e size of the ulcersranged from #.* to !.% cm in diameter (Figure !). Tooth !+was in the middle of endodontic treatment for wide anddeep caries lesion, and the radiograph showed no periapi-cal lesion (Figure "). Palpation and percussion of tooth !+were within normal limits. However, the patient consideredhaving tooth !+ extracted. Furthermore, enlarged and painfulsubmandibular lymph nodes were noted on palpation andwere possibly the result of in(ammation related to tooth !+.A working diagnosis of propolis-induced mucosal burns wasmade. 'e patient was advised to discontinue propolis useand was prescribed tetracycline mouthwash three times dailyfor *days andDoloneurobion twice daily for +days tomanagethe pain. She was advised to make a followup consultationa,er % days.
On the followup consultation, extra oral examinationindicated a normal appearance of the a)ected area. Tooth!+ had been extracted by a di)erent department, becausethe patient believed that it was the cause of the throbbingpain. Clinically, there was a healing extraction socket of tooth
F/0123 ": Dental radiograph showing the wide and deep carieslesion on tooth !+, with un.nished endodontic treatment. Noperiapical lesion was observed.
!+ and healing of the ulcerated area that was seen as theerythematous area. Pain related to the postulcerated area hadmainly resolved; however, she reported persistent throbbingpain in the area where tooth !+ had been extracted. Nosubmandibular lymphadenopathy was observed during thisvisit. Our department suspected trigeminal neuralgia as thecause of the throbbing pain. 'e patient was prescribed agauze mucosal compress with #.#%% chlorhexidine gluconatethree times daily for * days to heal the oral mucosa, inaddition to !##mg carbamazepine twice daily for % days.'epatient was asked to return for a followup consultation in %days.
On the .nal consultation, the erythematous area wascompletely healed, and the rest of the mucosa appearednormal, with the socket of tooth !+ healing a,er extraction(Figure *). 'e patient reported no pain related in thepostulcerated area. However, the throbbing pain in the areaof tooth !+ was noted as a “funny feeling.” A !##mg doseof carbamazepine was prescribed twice daily for " weeks.
'e ulcer was declared to be healed at this visit, and thepatient was scheduled for a followup consultation " weekslater for the further evaluation of the suspected trigeminalneuralgia.
3. Discussion
'e various biological bene.ts of propolis have resulted in itbeing widely used in medicine, including dentistry [!#, !!].Many in vitro and in vivo studies on propolis have beencompleted, with several clinical trials on humans showingits bene.cial use as an active ingredient for the treatmentof eosinophilic ulcers, as an antimicrobial for gingivitispatients, as a component of pulp capping materials, andas an antifungal for patients with denture stomatitis [!%–!+]. However, adverse reactions to propolis have also beenreported and described in the published literature [!", !*].A %#-year-old female patient with an oral lesion due to thetopical application of propolis was described in this casereport.
A,er careful analysis of the nature of the lesion, ourpatientwas diagnosed as having oralmucosal burns followingdirect contact with concentrated propolis.'e patient in thiscase report decided to compress the mucosa with a cottonroll damped with concentrated propolis to ease a throbbingpain in the a)ected area overnight.'e eruption of the lesionin the contact area happened approximately - hours a,erthe application of propolis, without any systemic conditions.'e high concentration of ethanol component (%#–+#%)in the propolis extract might be the cause of the mucosalburn. 'e propolis extract had been subject to a series ofextraction processes that use highly concentrated alcoholsbefore it is made publically available [!, !*].'is high alcoholcomponentmight have caused the damage to the oralmucosain this patient [!-]. In addition, keeping a cotton roll in themouth for several hours might have also caused trauma tothe oral mucosa. 'e ulcer completely healed a,er !" days,following the cessation of propolis use and the prescription
of appropriate antibiotics with anticollagenolytic e)ects, inparallel with antiseptics and supportive measures.
Although cases of allergic reactions to the topical appli-cation of propolis have been reported, we did not suspectthat this was the case for our patient [!&]. Our patient hada long history of propolis use in her daily life and had beenadding propolis to her drinkingwater, with no adverse e)ects.Many reports state that the median time for lesions related toallergy to propolis occurs a,er ".% days (range: #–!% days).In contrast, our patient developed the ulcer approximately- hours a,er propolis application [!&–""]. Studies on theallergic potential of propolis have revealed that it shouldnot be used as a topical product due to its high sensitizingcharacteristics [""].'e minor constituents in propolis, suchas *-methyl-"-butenyl ca)eate and phenyl-ethyl ca)eate, aremajor allergens, in addition to benzyl-salicylate and benzyl-cinnamate ["*]. We did not order a patch test to check for apossible allergic reaction of our patient to propolis.'erefore,we could not con.rm whether the oral ulceration was due toa propolis allergy within - hours of exposure [!&]. However,possible allergic contact mucositis that was facilitated byinjury to oral mucosa could be postulated.'is case report provides another alert to clinicians about
the potential adverse e)ect of propolis when used to treatoral diseases, as some propolis applications may have seriousnegative e)ects. Although there is an increasing global trendin the use of propolis formedication, the important discoveryof its bene.cial roles should be in parallel with researchundertaken to speci.cally de.ne its application in manyareas of dentistry. Careful consideration should be givenbefore using propolis to treat oral diseases, as many clinicalcomplications might arise, despite its natural origin ["$].
Conflict of Interests
'e authors declare that there is no con(ict of interestsregarding the publication of this paper.
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