Natural Oral Care in Dental Therapy
Scrivener Publishing
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Martin Scrivener (martin@scrivenerpublishing.com)
Phillip Carmical (pcarmical@scrivenerpublishing.com)
Natural Oral Care in Dental Therapy
Edited by
Durgesh Nandini Chauhan, Prabhu Raj Singh,
Kamal Shah and Nagendra Singh Chauhan
This edition first published 2020 by John Wiley & Sons, Inc., 111 River Street, Hoboken, NJ 07030, USA and Scrivener
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Library of Congress Cataloging-in-Publication Data
Names: Chauhan, Durgesh Nandini, editor. | Singh, Prabhu Raj, editor. | Shah, Kamal, editor. |
Chauhan, Nagendra Singh, editor.
Title: Natural oral care in dental therapy / edited by Durgesh Nandini Chauhan, Prabhu Raj Singh,
Kamal Shah and Nagendra Singh Chauhan.
Description: Hoboken, New Jersey : Wiley-Scrivener, [2020] | Includes bibliographical references and index.
Identifiers: LCCN 2019050429 (print) | LCCN 2019050430 (ebook) | ISBN 9781119614227 (cloth) |
ISBN 9781119618935 (adobe pdf) | ISBN 9781119618904 (epub)
Subjects: MESH: Mouth Diseases--drug therapy | Plants, Medicinal | Mouth Diseases--prevention & control |
Dental Care | Medicine, Traditional
Classification: LCC RK305 (print) | LCC RK305 (ebook) | NLM WU 166 | DDC 617.6/306--dc23
LC record available at https://lccn.loc.gov/2019050429
LC ebook record available at https://lccn.loc.gov/2019050430
ISBN 978-1-119-61422-7
Cover image: Pixabay.Com
Cover design by Russell Richardson
Set in size of 11pt and Minion Pro by Manila Typesetting Company, Makati, Philippines
Printed in the USA
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Contents
Preface
Foreword
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xxiii
Part I: Natural Oral Care
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Natural Oral Care in Dental Therapy: Current and Future Prospects
Durgesh Nandini Chauhan, Prabhu Raj Singh, Kamal Shah
and Nagendra Singh Chauhan
1.1 Introduction
1.2 Safety of Natural Oral Care
1.3 Advantage of Natural Oral Care
1.4 Limitations of Natural Oral Care
1.5 Future Prospects of Natural Oral Care
References
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Herbal Products for Oral Hygiene: An Overview of Their Biological Activities
Ummuhan Sebnem Harput
2.1 Introduction
2.2 Oral Hygiene and Current Treatments
2.3 Plants Traditionally Used in Oral Hygiene
2.4 Clinically Studied Plant Product for Oral Hygiene
2.5 In Vitro Studied Herbal Product for Oral Hygiene
2.6 Discussion
2.7 Conclusion
References
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Go Green—Periodontal Care in the Natural Way
Siddhartha Varma and Sameer Anil Zope
3.1 Introduction
3.2 Plaque Control
3.3 Dant Dhavani (Brushing)
3.4 Jivha Lekhana (Tongue Scrapping)
3.5 Gandusha (Gargling) or Oil Pulling
3.6 Oxidative Stress in Periodontitis
3.7 Green Tea
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3.8
3.9
3.10
3.11
3.12
3.13
3.14
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3.18
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3.22
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3.24
3.25
3.26
3.27
3.28
3.29
4
3.7.1 Components
3.7.2 Beneficial Effects of Various Tea Components
3.7.2.1 Antioxidative Effect
3.7.3 Role in Managing Periodontitis
Turmeric (Curcumin longa, Haldi)
3.8.1 Applications of Turmeric in Dentistry
Amala (Emblica officinalis, Amalaki, Phyllanthus emblica,
Indian Gooseberry, Dhatriphala)
Anar/Dalima (Punica granatum)
Launga/Clove (Syzygium aromaticum)
Gotu Kola (Centella asiatica)
Amra/Mango (Magnifera indica)
Neem (Azadirachta indica)
Tulsi (Ocimum sanctum)
Nilgiri (Eucalyptus globulus)
Tila/Sesame (Sesamum indicum)
Triphala
Tea Tree Oil (Melaleuca Oil)
Rumi Mastagi/Mastic Gum (Pistacia lentiscus)
Wheat Grass
Goldenseal (Hydrastis canadensis)
Licorice Root
Myrrh (Commiphora glileadenis)
Psidium guajava
Ginkbo Biloba
Honey
Other Herbs Which Can Be Potentially Used for Treating Periodontitis
Conclusion
References
Role of Herbal and Natural Products in the Management
of Potentially Malignant Oral Disorders
P. Kalyana Chakravarthy, Komal Smriti and Sravan Kumar Yeturu
4.1 Introduction
4.2 Oral Submucous Fibrosis (OSMF)
4.2.1 Background
4.2.2 Beta-Carotene
4.2.3 Lycopene
4.2.4 Aloe Vera
4.2.5 Colchicine
4.2.6 Tea Pigments
4.2.7 Spirulina
4.2.8 Chinese Herbal Medicines
4.2.9 Turmeric and Derivatives, Nigella sativa, Ocimum
4.2.10 Polyherbal Formulations
4.2.11 Ayurvedic Formulations
4.2.12 Conclusion
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4.3 Oral Leukoplakia (OL)
4.3.1 Background
4.3.2 Green Tea and Extracts
4.3.3 Beta-Carotene (βC)
4.3.4 Lycopene
4.3.5 Curcumin
4.3.6 Miscellaneous
4.3.6.1 Alpha-Tocopherol
4.3.6.2 Chinese Herbs
4.3.6.3 Bowman–Birk Inhibitor Concentrate (BBIC)
4.3.7 Conclusion
4.4 Oral Lichen Planus (OLP)
4.4.1 Conclusion
References
Part II: Studies of Plants Used in Dental Disease
5
6
Studies on the Anticariogenic Potential of Medicinal Plant Seed
and Fruit Extracts
Disha M. Patel, Jenabhai B. Chauhan and Kalpesh B. Ishnava
5.1 Introduction
5.2 Materials and Methods
5.2.1 Plant Materials
5.2.2 Preparation of Plant Seed and Fruit Extracts
5.2.3 Cariogenic Bacterial Strains
5.2.4 Preparation of Inoculums
5.2.5 Anticariogenic Activity Screening of Plant Extracts
5.2.5.1 Agar Well Diffusion Assay
5.2.5.2 Determination of Minimum Inhibitory Concentration (MIC)
5.2.6 Preliminary Phytochemical Analysis
5.2.7 Analytical Thin Layer Chromatography
5.2.8 TLC—Bioautography
5.3 Result and Discussion
5.3.1 MIC Value of Effective Plant Extracts
5.3.2 Phytochemical Screening and Bioautography
5.4 Conclusion
Acknowledgments
References
Cytotoxic and Anti-Inflammatory Effect of Turmeric and Aloe Vera
in a Gingivitis Model
Karen Esperanza Almanza-Aranda, Miguel Aranda-Fonseca,
Gabriela Velazquez-Plascencia and Rene Garcia-Contreras
6.1 Introduction
6.2 Gingivitis and Periodontitis
6.3 Aloe Vera
6.3.1 Aloe Vera for Gingivitis and Periodontitis
6.3.2 Aloe Vera: Other Oral Applications
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viii Contents
6.4 Turmeric
6.4.1 Turmeric for Gingivitis and Periodontitis
6.4.2 Turmeric: Other Oral Applications
6.5 Methodology
6.5.1 Materials and Methods
6.5.1.1 Authorization
6.5.1.2 Cell Culture
6.5.1.3 Cell Subculture
6.5.1.4 Cytotoxicity Test
6.5.1.5 Anti-Inflammatory Activity in a Gingivitis Model
6.5.1.6 Statistical Analysis
6.5.2 Results
6.5.2.1 Cytotoxicity
6.5.2.2 Anti-Inflammatory Activity in a Gingivitis Model
6.5.3 Discussion
6.5.3.1 Cytotoxicity
6.5.3.2 Anti-Inflammatory Activity
6.6 Perspectives for the Future
6.7 Conclusions
References
7
Effects of Bauhinia forficata Link in Reducing Streptococcus mutans
Biofilm on Teeth
Julio Cesar C. Ferreira-Filho, Mariana Leonel Martins, Andressa Temperini de
Oliveira Marre, Juliana Soares de Sá Almeida, Leandro de Araújo Lobo,
Adriano Gomes Cruz, Marlon Máximo de Andrade, Thiago Isidro Vieira,
Maria Teresa Villela Romanos, Lucianne Cople Maia, Ana Maria Gondim
Valença and Andréa Fonseca-Gonçalves
7.1 Introduction
7.2 Materials and Methods
7.2.1 Recognition, Production, and Chemical Characterization of
Ethanolic Tincture From B. forficata L. Leaves
7.2.2 Microbial Strains and Preparation of Inoculum
7.2.3 Minimum Inhibitory Concentration and Minimum Bactericidal
Concentration (MBC)
7.2.4 Kill-Kinetic Assay
7.2.5 Cytotoxic Potential
7.2.6 Tooth Selection and Preparation for Microbiologic Assay Using
an S. mutans Biofilm
7.2.7 Statistical Analysis
7.3 Results and Discussion
7.4 Final Considerations
Acknowledgments
References
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Antimicrobial Effect of a Cardamom Ethanolic Extract on Oral Biofilm:
An Ex Vivo Study
Marina Fernandes Binimeliz, Mariana Leonel Martins,
Julio Cesar Campos Ferreira Filho, Lucio Mendes Cabral,
Adriano Gomes da Cruz, Lucianne Cople Maia and Andréa Fonseca-Gonçalves
8.1 Introduction
8.2 Materials and Methods
8.2.1 Cardamom Extract Production
8.2.2 Physical Analyses
8.2.3 Bacterial Strains and Determination of Minimum Inhibitory
Concentration and Minimum Bactericidal Concentration
8.2.4 Salivary Collection for Biofilm Formation (Ex Vivo Experiment)
8.2.5 Biofilm Formation and Treatment
8.2.6 Statistical Analyses
8.3 Results and Discussion
8.4 Final Considerations
Acknowledgment
References
Effect of Punica granatum Peel Extract on Growth of Candida albicans
in Oral Mucosa of Diabetic Male Rats
Maryam Eidi and Fatemeh Noorbakhsh
9.1 Introduction
9.2 Materials and Methods
9.2.1 Hydro-Methanolic Extract
9.2.2 Candida albicans Inoculation
9.2.3 Animal
9.2.4 Statistical Analysis
9.3 Results and Discussion
9.4 Conclusion
Acknowledgment
References
Part III: Applications of Natural Products in Oral Care
10 Effect of Oil Pulling on Oral Health
Sameer Anil Zope and Siddhartha Varma
10.1 Introduction
10.2 What Is Oil Pulling (Snaihik Gandoosh)?
10.3 How Does Oil Pulling Work?
10.4 Composition and Various Activities of Most Commonly Used Oils
for Oil Pulling
10.4.1 Sesame Oil
10.4.1.1 Antioxidant Activity
10.4.1.2 Antimicrobial Activity
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10.4.2 Coconut Oil
10.4.2.1 Antibacterial, Antifungal, and Antiviral Activity
10.4.2.2 Antinociceptive, Anti-Inflammatory, Antioxidant,
and Anti-Ulcer Activity
10.5 Procedure of Oil Pulling
10.6 Effects of Oil Pulling on Oral Health
10.6.1 Dental Caries
10.6.2 Plaque-Induced Gingivitis
10.6.3 Halitosis
10.6.4 Oral Thrush
10.6.5 Xerostomia and Burning Mouth Syndrome
10.7 Drawbacks of Oil Pulling
References
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11 Role of Proteolytic Enzymes in Dental Care
P. Kalyana Chakravarthy and Sravan Kumar Yeturu
11.1 Introduction
11.2 Role of Proteolytic Enzymes in Oral Surgery
11.2.1 Post-Extraction Management
11.2.2 Post-Surgical Facial Ecchymosis and or Edema
11.2.3 Enhanced the Action of Antibiotics
11.2.4 Effect of Bromelain on Blood Coagulation and Fibrinolysis
11.3 Role of Proteolytic Enzymes in Cancer and Oral Mucositis
11.3.1 Cancer
11.3.2 Management in Oral Mucositis
11.4 Osteoarthritis
11.5 Anti-Microbial Action
11.6 Treatment of Dental Carious Lesions
11.6.1 Laboratory Studies
11.6.2 Clinical Studies
11.7 Improvement in Bonding of Orthodontics Brackets
11.8 Role on Biofilm Control (Plaque, Gingivitis, and Oral Malodor)
11.9 Extrinsic Stain Removal on the Teeth
11.10 Role in Replantation of the Avulsed Tooth
11.11 Effect of Bromelain on Immunogenicity
11.12 Other Possible Applications and Scope for Future Research
References
153
12 The Effect of Probiotic on Oral Health
Patricia Nadelman, Marcela Baraúna Magno, Mariana Farias da Cruz,
Adriano Gomes da Cruz, Matheus Melo Pithon, Andréa Fonseca-Gonçalves
and Lucianne Cople Maia
12.1 Introduction
12.2 Overview of Oral Communities and Probiotic-Based Therapy
to Oral Dysbiosis
12.3 Probiotics Mechanisms of Action
12.4 Dental Caries
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Contents
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12.4.1 Definition and Etiopathology
12.4.2 Probiotics and Dental Caries
12.4.3 Probiotic-Contained Dairy Products and Dental Caries
12.4.4 Probiotic Powder and Dental Caries
12.4.5 Probiotic Tablets and Lozenges and Dental Caries
12.4.6 Probiotic Mouthwashes and Dental Caries
Periodontal Disease
12.5.1 Definition and Etiopathology
12.5.2 Probiotics and Periodontal Diseases
Oral Candidiasis
12.6.1 Definition and Etiopathology
12.6.2 Probiotics and Oral Candidiasis
Halitosis
12.7.1 Definition and Etiopathology
12.7.2 Probiotics and Halitosis
Conclusion
Acknowledgments
References
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13 Charcoal in Dentistry
Abhilasha Thakur, Aditya Ganeshpurkar and Anupam Jaiswal
13.1 Introduction
13.2 Charcoal Production Methods
13.2.1 The Traditional Method
13.2.2 The Modern Methods
13.3 Uses of Charcoal
13.3.1 Medicinal Uses
13.3.2 Non-Medicinal Uses
13.4 Charcoal Containing Oral and Dental Care Products
13.5 Benefits of Using Charcoal Containing Oral
and Dental Care Products
13.5.1 Removes Stains and Whitens Teeth
13.5.2 Removes Acidic Plaque
13.5.3 Gives Fresh Breath and Improves Halitosis
13.5.4 Remineralize Teeth
13.5.5 Helps Overall Dental Health
13.5.6 Protects From Infection
13.5.7 Cost Effective for Regular Basis Use
13.6 Precautions to be Taken While Using Charcoal Containing Oral
and Dental Care Products
13.7 Conclusion
References
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12.5
12.6
12.7
12.8
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14 Propolis Benefits in Oral Health
Mariana Leonel Martins, Karla Lorene de França Leite,
Yuri Wanderley Cavalcanti, Lucianne Cople Maia and
Andréa Fonseca-Gonçalves
14.1 Introduction
14.2 Types of Propolis
14.2.1 Brown Propolis
14.2.2 Green Propolis
14.2.3 Red Propolis
14.3 Biological Properties of Propolis
14.3.1 Oral Antibacterial Activity
14.3.2 Oral Antifungal Activity
14.4 Other Biological Properties of Propolis
14.4.1 Anti-Inflammatory Activity
14.4.2 Antioxidant Activity
14.4.3 Anticancer Activity
14.5 Benefits for Oral Health and Applications in Dentistry
14.6 Final Considerations
Acknowledgment
References
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15 Grape Seed Extract in Dental Therapy
Anusuya V, Ashok Kumar Jena and Jitendra Sharan
15.1 Introduction
15.2 Part I: Basics About Grape Seed Extracts
15.2.1 Components of Grape Seed Extracts
15.2.2 Chemical Structure
15.2.3 Types of GSEs
15.2.4 Methods of Separation
15.2.5 Factors Influencing the Quality and Quantity of Polyphenols
in the GSEs
15.2.6 Physical Properties of Polyphenols
15.2.7 Biochemical Properties (Biological and Pharmacological)
15.3 Part II: Biological Applications in Dentistry
15.3.1 GSEs in Dental Caries
15.3.2 Anti-Erosive Agent (Prevention of Enamel erosion)
15.3.3 Antiplaque Effect
15.3.4 Antibacterial Agent
15.3.5 Biomodifier
15.3.6 GSEs as a Remineralizing Agent—Existing Dilemma
15.4 GSEs in Restorative Dentistry
15.4.1 GSE as Cross-Linking Agent
15.4.2 GSE in Bonding
15.5 GSEs in Endodontic Treatment
15.5.1 Endodontic Irrigants
15.5.2 Post Endodontic Restorations
15.6 GSEs in Periodontics
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15.6.1 Anti-Inflammatory Action in Periodontitis
15.6.2 Anti-Oxidative Action in Periodontitis
15.6.3 Antibacterial Action Against Periodontal Pathogens
15.6.4 Antimicrobial Activity in Peri-Implantitis
15.7 GSEs in Oral Cancer
15.8 Conclusion
References
16 Ocimum Sanctum L: Promising Agent for Oral Health Care Management
Trinette Fernandes, Anisha D’souza and Sujata P. Sawarkar
16.1 Introduction
16.2 History of Ocimum sanctum
16.3 Chemical Constituents of Ocimum sanctum
16.4 Therapeutic Significance of Ocimum in Dental Health and Preventive
Care Management
16.5 Novel Drug Delivery Formulations and Its Application in Dentistry
16.5.1 Nanofibers
16.5.2 β-Cyclodextrin Complexes
16.5.3 Nanoparticles of Biocompatible Ocimum sanctum-Coated
Silver Nanoparticles
16.6 Conclusion
References
17 Coconut Palm (Cocos nucifera L.): A Natural Gift to Humans
for Dental Ministrations
Navneet Kishore and Akhilesh Kumar Verma
17.1 Introduction
17.2 Traditional Usage and Ethnopharmacological Relevance
17.3 Pharmacological Properties of Coconut
17.4 Role of Coconut Tree in Dental Ministrations
17.5 Exemplary Potential of Coconut Water in Dentistry
17.6 Other Significance of Coconut
17.6.1 Economic Value of Coconut Leaves
17.6.2 Use of Coconut Heart
17.6.3 Significance of Spathe and Inflorescence
17.6.4 Potential of Coconut Fruits
17.6.5 Usage of Coconut Milk
17.6.6 Importance of Coconut Shell
17.6.7 Commercial Usage of Husk Fibers
17.6.8 Economic Importance of Coconut Stems
17.6.9 Convention of Coconut Roots
17.7 Active Constituent Identified from Coconut
17.8 Future Prospective
17.9 Conclusions
Acknowledgments
References
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18 Salvadora persica L. (Miswak): An Effective Folklore Toothbrush
Sujata P. Sawarkar, Anisha D’souza and Trinette Fernandes
18.1 Introduction
18.2 History
18.3 Chemical Constituents
18.4 Extraction, Isolation, Identification of Chemical Constituents
18.5 Pharmacology—Therapeutic Activity of Salvadora persica L.
18.5.1 Theories for Miswak Activities
18.5.2 Antibacterial and Antifungal
18.5.3 Anti-Viral Effect
18.5.4 Anti-Cariogenic Effect
18.5.5 Antiplaque Effect
18.5.6 Antiperiodontitis Effect
18.5.7 Whitening Effect
18.6 Conclusion
References
285
19 Triphala and Oral Health
Kamal Shigli, Sushma S Nayak, Mrinal Shete, Vasanti Lagali Jirge
and Veerendra Nanjwade
19.1 Introduction
19.2 Taxonomical Classification
19.3 Chief Phytoconstituents
19.4 Role of Triphala in Dentistry
19.4.1 Anti-Caries Activity
19.4.2 Triphala as a Root Canal Irrigant
19.4.3 Anti-Microbial and Anti-Oxidant Effect of Triphala
19.4.4 Role of Triphala in Periodontal Diseases
19.4.5 Triphala as a Mouth Rinse
19.4.6 Anti-Candida Activity of Triphala
19.4.7 Anti-Collagenase Activity of Triphala
19.5 Pharmacological Activities of Triphala and Future Research
19.5.1 Anticancer and Antioxidant Activity of Triphala
19.5.2 Wound Healing Properties
19.5.3 Antibacterial Activity of Triphala
19.5.4 Anti-Diabetic Effect
19.5.5 Anti-Inflammatory, Analgesic, and Antipyretic Effect
19.5.6 Immunomodulatory Effect
19.6 Public Health Importance
19.7 Formulation Using Triphala
19.6 Conclusion
References
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20 Azadirachta indica (Neem): An Ancient Indian Boon to the
Contemporary World of Dentistry
Sri Chandana Tanguturi, Sumanth Gunupati and Sreenivas Nagarakanti
20.1 Introduction
20.2 Vital Bioactive Compounds of Neem
20.2.1 Nimbidin
20.2.2 Azadirachtin
20.2.3 Nimbolide
20.2.4 Gedunin
20.2.5 Mahmoodin
20.2.6 Tannins
20.2.7 Diterpenoids
20.3 How to Distinguish Azadirachta Indica (Neem) from its
Common Adulterant Melia Azedarach
20.4 Therapeutic Applications of Neem
20.4.1 Neem as an Anti-Inflammatory, Analgesic Agent
20.4.2 Antioxidant Activity
20.4.3 Anticancerous Activity
20.4.4 Antimicrobial Activity
20.4.4.1 Antibacterial Activity
20.4.4.2 Antiviral Activity
20.4.4.3 Antifungal Activity
20.4.4.4 Antimalarial Activity
20.4.5 Wound Healing Effect
20.5 Applications of Neem in Dentistry
20.5.1 Neem in Treatment of Periodontal Diseases
20.5.2 Role of Neem in Endodontics
20.5.3 Potent Role of Neem in Preventive Dentistry
20.5.3.1 Application in Dental Erosion Therapy
20.5.3.2 Anti-Microbial Activity
20.5.3.3 Anticaries Activity of Neem
20.5.3.4 Anti-Candidiasis Property
20.5.3.5 Anti-Cancer Property
20.6 Literature Supporting the Use of Neem in Dentistry
20.7 Toxicity and Safety
20.8 Contamination and Adulteration
20.9 Drug Interactions
20.10 Neem’s Prospects in Dentistry
20.11 Action Points and Recommendations for Health Care Professionals
20.12 Conclusion
References
21 Ginger in Oral Care
Aditya Ganeshpurkar, Abhilasha Thakur and Anupam Jaiswal
21.1 Introduction
21.2 Description
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321
321
321
322
322
322
323
323
323
324
329
329
330
xvi
Contents
21.3
21.4
21.5
21.6
Macroscopic Characteristics
Pharmacognostic Standards
Nutrient Composition
Pharmacological and Medicinal Effects
21.6.1 Oral Analgesic Effect
21.6.2 Antimicrobial Effect
21.6.3 Anti-Carries Activity
21.6.4 Anti-Decay Effect
21.6.5 Healing Effect in Root Canal Therapy
21.6.6 Anti-Xerostomia Effect
21.6.7 Anti-Pyorrhea Effect
21.6.8 Anti-Thrush Effect
21.6.9 Anti-Herpes Effect
21.6.10 Tooth Polishing
21.6.11 Mouth Deodorizing Effect
21.6.12 Anticancer Effect
21.6.13 Protection Against Aphthous Stomatitis
21.6.14 Effect on Dentin Hardness
21.7 Pharmacokinetics
21.8 Toxicological Studies
21.9 Conclusion
References
22 Effectiveness of Allium sativum on Bacterial Oral Infection
Vesna Karic, Anupam Jaiswal, Heidi Abrahamse, Abhilasha Thakur
and Aditya Ganeshpurkar
22.1 Introduction
22.1.1 History and Origin of Garlic
22.1.2 Medicinal Values of Garlic
22.2 Types of Allium sativum
22.2.1 Allium sativum Ophisocorodon/Hard-Necked Garlic
22.2.2 Allium sativum Sativum/Soft-Necked Garlic
22.3 Chemical Constituents
22.3.1 Allicin
22.3.2 Ajoenes
22.3.3 Alliin
22.4 Dental Infections and Epidemiology
22.5 Dental Infection and Antibiotic Resistance
22.6 The Antibacterial Application of Garlic in Dentistry
22.6.1 The Use of Garlic to Treat Oral Infections
22.6.1.1 Periodontitis
22.6.1.2 Pediatric Endodontitis
22.6.1.3 Dental Caries
22.6.1.4 Denture Stomatitis
22.6.1.5 Protection Against Fibrosis
22.6.1.6 Garlic Chewing Gum
22.6.1.7 Garlic Used as a Breath-Freshening Agent
330
330
331
331
331
332
333
333
334
334
335
335
336
336
336
338
338
338
339
339
339
340
345
345
347
348
349
349
349
351
351
351
351
352
352
354
354
354
356
357
358
359
359
359
Contents
22.7 Additional Use of Garlic in Dentistry—Oral Cancer
22.7.1 High Blood Pressure
22.7.2 Skin Disorders
22.7.3 Anti-Allergic
22.7.4 Anti-Obesity
22.8 Garlic Mechanism of Action
22.9 Conclusions and Recommendations
Acknowledgments
References
Part IV: Ethnobotany and Ethanopharmacology
xvii
360
361
362
362
362
362
362
364
364
371
23 Curative Plants Worn in the Healing of Mouth Evils
P. Shivakumar Singh, Pindi Pavan Kumar and D. Srinivasulu
23.1 Introduction
23.2 Materials and Methods
23.3 Results and Discussion
23.4 Conclusion
Acknowledgment
References
373
24 Ethnopharmacological Applications of Chewing Sticks on Oral Health Care
E. A. Akaji and U. Otakhoigbogie
24.1 Introduction
24.1.1 Background
24.1.2 Historical Perspectives
24.1.3 Sources and Types of Chewing Sticks
24.2 Applications of Chewing Sticks in Oral Health Care
24.2.1 Chewing Sticks for Oral Hygiene
24.2.2 Ethnopharmacological Applications of Chewing Sticks
in Oral Health
24.2.2.1 Dental Caries (Tooth Decay)
24.2.2.2 Periodontal Disease
24.2.2.3 Oral Candidiasis
24.2.2.4 Oral Ulcers and Halitosis
24.2.2.5 Other Oral Conditions
24.3 Conclusions
References
383
25 Ethnomedicine and Ethnopharmacology for Dental Diseases in Indochina
Viroj Wiwanitkit
25.1 Introduction
25.2 Ethnomedicine and Ethnopharmacology in Indochina
25.3 Locally Available Naturally Derived Dental Products in Indochina
25.4 Ethnopharmacology for Dental Diseases in Indochina
25.5 Ethnomedicine for Dental Diseases in Indochina
393
373
374
375
381
381
381
383
383
384
384
384
384
387
387
389
389
390
390
390
391
393
394
396
397
402
xviii
Contents
25.6 Future Trend of Ethnomedicine and Ethnopharmacology
for Dental Diseases in Indochina
25.7 Conclusion
References
403
404
404
26 Traditional Medicinal Plants Used in Anti-Halitosis
P. Shivakumar Singh, Pindi Pavan Kumar and D. Srinivasulu
26.1 Introduction
26.2 Materials and Methods
26.3 Results and Discussion
26.4 Conclusion
Acknowledgment
References
407
Index
415
407
408
409
412
413
413
Preface
For hundreds of years now the existence and utility of natural products have bolstered the
idea that natural products are still the choice for therapy. Their structural diversity and
exclusive pharmacological actions differentiate them from drugs of synthetic origin. Not
only are they used in traditional ways but also in modern medicine for treating lifethreatening diseases. The discovery and design of new drugs from natural products always
remain a challenging task. Still, they remain a choice due to their safety profile and negligible side effects. This book focuses on perspectives of natural medicine in various dental diseases. Oral diseases continue to be a major health problem worldwide. Oral health
is integral to general well-being and relates to the quality of life that extends beyond the
functions of the craniofacial complex. Standard Western medicine has had only limited
success in the prevention of periodontal disease and treatment of a variety of oral diseases.
The dentist needs to be more informed regarding the use, safety, and effectiveness of the
various traditional medicines and over-the-counter products. For example, herbal extracts
have been used in dentistry for reducing inflammation, as antimicrobial plaque agents, for
preventing the release of histamine and as antiseptics, antioxidants, antimicrobials, antifungals, antibacterials, antivirals, and analgesics. They also aid in healing and are effective in
controlling microbial plaque in gingivitis and periodontitis, thereby improving immunity.
The 26 chapters of this book cover the chemistry, clinical and preclinical panorama of
natural products used in oral care. In Chapter 1, Chauhan et al. provide an exhaustive list
of natural oral care products used in oral diseases and classify them according to use and
chemistry. Chapter 2, contributed by Harput, discusses the crucial role that oral hygiene
plays in the prevention of oral diseases, including periodontitis, tooth decay, and oral
candidiasis. In Chapter 3, Varma and Zope highlight the herbs and their extracts used as
an adjuvant in periodontal disease treatment. Chapter 4, written by Chakravarthy et al.,
focuses on various modalities currently available and discusses the efficacy and safety of
such herbal products and natural extracts in the management of potentially malignant oral
disorders. In Chapter 5, Patel et al. discuss experimental studies that show the promising
broad spectrum anticariogenic activity of ethyl acetate and methanolic extract of Quercus
infectoria that may prove useful for the clinical evaluation and development of a formulation suitable for the treatment of dental caries. Chapter 6, by Almanza-Aranda et al., reports
that turmeric and Aloe vera in culture with HGF show promising potential and have clinical use for patients with gingivitis and periodontitis. In a study reported in Chapter 7,
Ferreira-Filho et al. evaluate the effects of a tincture made from Bauhinia forficata Link
leaves (TBF) on Streptococcus mutans biofilm formed on teeth. In Chapter 8, Binimeliz et
al. demonstrate the effect of an Elettaria cardamomum ethanolic extract (ECE) against oral
biofilm bacteria through an in vitro study. Chapter 9, contributed by Eidi and Noorbakhsh,
xix
xx Preface
reports on the effect of Punica granatum peel extract on the growth of Candida albicans in
the oral mucosa of diabetic male rats. In Chapter 10, Zope and Varma give an overview of
the evidence-based use of oil pulling therapy in the maintenance of oral health. The focus
of Chapter 11 by Chakravarthy and Yeturu is plant-based proteolytic enzymes, including
papain, bromelain, actinidin, and ficin; as well as the application of these enzymes in professional as well as personal oral health care. The aim of Chapter 12 by Nadelman et al. is
to present an updated viewpoint of the effect of probiotics on oral health by describing the
relationship between the administration/consumption of these bacteria and the main oral
dysbiosis, the oral microbiota parameters, and the immune salivary components. Chapter
13, written by Thakur, highlights the role of charcoal in dentistry and the development of
charcoal-based dentifrices. In Chapter 14, Martins et al. present an updated review of the
benefits of propolis in oral health, and the subject of Chapter 15 by Anusuya et al. is the
role of grape seed extract in dentistry. In Chapter 16, Fernandes et al. discuss the use of
Ocimum sanctum L for oral care and halitosis, which, because of its anticariogenic properties, is also used in periodontal diseases such as periodontitis and gingivitis. This chapter
not only discusses its conventional formulation but also O. sanctum L formulations loaded
in a promising novel drug delivery system. Chapter 17, authored by Kishore and Verma,
presents the latest information regarding traditional, ethnopharmacological, and bioactive
phytochemicals and the significant use of coconut plant in oral cavity therapies. In Chapter
18, Sawarkar et al. discuss the use of miswak for maintaining oral health and its various
commercial products. Shigli et al. write about triphala in Chapter 19 and demonstrate its
traditional use and newer pharmacologic activities for use as an adjuvant mainstream drug
in dentistry as well as in general medicine. The role that Azadirachta indica (neem) plays in
dentistry is revealed by Tanguturi et al. in Chapter 20. In Chapter 21, Ganeshpurkar reveals
the lethal effect ginger has on the growth of tooth-decaying bacteria since it is a good dental
analgesic and promotes dentine remineralization. Moreover, the antiplaque and mouthdeodorizing effects of ginger are also well documented. The aim of Chapter 22 by Karic et
al. is to raise awareness on the use of garlic formulations to reduce the risk of oral disease
and dental caries. In Chapter 23, Singh and Rao discuss the traditional uses of plants in the
treatment of mouth evils at Kosgimandal of Naryanapet District of Telangana State, India.
Chapter 24 by Akaji and Otakhoigbogie reveals the healing power of plant materials, such
as a chewing stick, primarily used for oral hygiene. In Chapter 25, Wiwanitkit discusses
ethnomedicine and ethnopharmacology for dental diseases in Indochina, a tropical region
in Asia, and Chapter 26 by Singh and Reddy enlists traditional medicinal plants with antihalitosis efficacy.
This important new volume will be valuable to dentists, oral hygienists, pharmacognosy
experts, and natural product formulation scientists alike, either as a textbook or a reference.
It is a must-have addition to any dental or herbal industry library. The aim of this book is
to be a reference for all those interested in the development of natural oral care as an alternative treatment.
Preface xxi
Last, but not the least, we would like to express our sincere gratitude to all the authors
who have taken time out from their busy schedules to be part of this project and have
written wonderful chapters that add both to the depth and value of this book. We welcome
suggestions and criticisms from our readers. We also acknowledge our mentor Prof. V.K.
Dixit Sir for his valuable guidance. Special thanks to our families for their support and
encouragement. We express our gratitude to the publishing and production team, especially
Martin Scrivener, for their kind, proficient, and encouraging guidance.
Durgesh Nandini Chauhan
Prabhu Raj Singh
Kamal Shah
Nagendra Singh Chauhan
December 2019
Foreword
Teeth are unique in the fact that, on one hand, they live for thousands
of years and are often encountered in archeologic excavations, and on
the other hand, we see rampant caries destroying almost all teeth in
children. Dental and oral health remains a definitive part of one’s overall health and wellbeing and helps one present oneself with confidence.
The care of the oral cavity has been described as early as the Sushruta
Samhita and in Hippocrates’ works. With evolution, there has been a
constant change in the environmental factors, the food, oral hygiene
measures, as well as products used in dental care. As we look back in time, one can appreciate that the traditional methods of oral care and their incorporation in current measures
may be the way forward to sustainable dental and oral health in the future. This book entitled Natural Oral Care in Dental Therapy by Chauhan et al. has come a long way in establishing this connection.
Prevention is better than cure is a dictum that has repeatedly established itself. Modern
dental science encourages oral hygiene measures based on mechanical and chemical cleansing, with continuous research on the chemical agents. Time and again, those agents and
natural remedies described in history are proving to be fruitful. There are lots of research
activities that have been started by academic institutions and research centers along with
their industrial partners, for the development of natural product formulation in dental
therapy. Thus, this book is a timely reference work for the scientific community.
Natural Oral Care in Dental Therapy is an applications-oriented book in the field of dental science. The book is a perfect resource for dentists, oral hygienists, herbal experts, phytochemists, research professionals, and technology investors. It is edited by an experienced
and interdisciplinary group comprising a well-respected dentist, clinician, natural product,
and pharmacology expert. I hope this book will inspire many current and future generations
of academic and industrial researchers to expand the use of natural products in dentistry.
Dr. Santhosh Rao
BDS, MDS, FIBOMS
Oral & Maxillofacial Surgeon
Associate Professor
Department of Dentistry
All India Institute of Medical Sciences,
Raipur, India
August 2019
xxiii
Part I
NATURAL ORAL CARE
1
Natural Oral Care in Dental Therapy:
Current and Future Prospects
Durgesh Nandini Chauhan1*, Prabhu Raj Singh2, Kamal Shah3 and Nagendra Singh Chauhan4
1
Columbia Institute of Pharmacy, Raipur, Chhattisgarh, India
MKD Muti Speciality Dental Clinic, Annupur, Madhy Pradesh, India
3
Institute of Pharmaceutical Research, GLA University, Chaumuha, Mathura, (U.P.) India
4
Drugs Testing Laboratory Avam Anusandhan Kendra, Raipur Chhattisgarh, India
2
Abstract
Nowadays, natural medicines like honey, clove, miswak, and propolis are a part of dental treatment
due to their reduced toxicity, wide availability, and cost effectiveness. This chapter gives an insight to
the reader about the potential use of natural products in current dentistry. They are in many forms
and include chewing sticks, oils, herbal extracts, minerals, animal products (e.g., honey), herbs,
herbal materials, herbal preparations, and finished herbal products that contain parts of plants or
other plant materials as active ingredients. Natural medicines hold huge benefits as adjunctive therapeutic uses in dentistry. Use of these techniques with suitable dosage would benefit the general
population by preventing various dental problems.
Keywords: Antiplaque, dentistry, antimicrobial, natural, oral health care, herbal, phytochemical,
medicinal plants
1.1 Introduction
Oral health is a key indicator of overall health, well-being, and quality of life. The World
Health Organization (WHO) defines oral health as “a state of being free from chronic
mouth and facial pain, oral and throat cancer, oral infection and sores, periodontal (gum)
disease, tooth decay, tooth loss, and other diseases and disorders that limit an individual’s
capacity in biting, chewing, smiling, speaking, and psychosocial well-being” [1].
There are seven major oral diseases and conditions reported for most of the oral disease
burden.
1. Dental caries (tooth decay)
2. Periodontal (gum) diseases
3. Oral cancers
*Corresponding author: pharmanandini@gmail.com
Durgesh Nandini Chauhan, Prabhu Raj Singh, Kamal Shah, and Nagendra Singh Chauhan (eds.)
Natural Oral Care in Dental Therapy, (3–30) © 2020 Scrivener Publishing LLC
3
4
Natural Oral Care in Dental Therapy
4.
5.
6.
7.
Oral manifestations of HIV
Oro-dental trauma
Cleft lip and palate
Noma
Oral diseases affect at least 3.58 billion people worldwide, with caries of the permanent teeth being the most common of all conditions assessed. Worldwide, it is estimated that 486 million children suffer from caries of primary teeth, and 2.4 billion
people suffer from caries of permanent teeth as per study on the Global Burden of
Disease Study 2016 [2].
Natural oral care rises to a growing trend in the increased use of “over-the-counter”
dental product. Nowadays, there is a huge range of natural oral care products and technology available that are self used without consulting an expert. The potential use of
natural product in current dentistry is obtained from plants, animals, marine animals,
and minerals sources (Figure 1.1). Minerals like alum, sodium bicarbonate, and sodium
chloride are commonly used in dentistry. The use of an alum mouthrinse daily inhibited
caries development in children with decay-prone teeth [3]. The saturated saline rinse
and alum rinse showed statistically significant reductions in salivary S. mutans counts in
children [4]. Intrinsic tooth stain was reduced using sodium chloride with vinegar [5].
Sodium bicarbonate acts as an antiadhering agent for bacteria [6]. Cheese and cow milk
stimulates salivary secretion and increases plaque calcium concentration and protection
from caries [7, 8].
Natural products have been used in dentistry as analgesic and local anesthetic, as
antimicrobial plaque agents, as antiseptics, whitening agent, antibacterials, to prevent
adhesion of bacteria, antianxiety, and anti-halitosis. Commonly used natural products
are Azadirachta indica, Syzygium Aromaticum, Acacia catechu, Aloe vera, miswak, and
propolis. Plants are also used in root canal irrigation, pulpal and dentin repair, solvents,
sealer cements, natural antioxidants, and storage medium (Table 1.1). Morinda citrifolia,
propolis, Triphala, and aloe vera, besides their oral care activity also act as additives in
Animal
Eg. Propolis, Honey
Plants
Probiotics
Eg.
Clove, Miswak, Neem
etc
Minerals
Eg. sodium
chloride, alum
Figure 1.1 Sources of natural care used in dental.
Eg. Lactobacillus
Natural
Care used
in Dental
Marine
Eg. alginate,
carrageenan,
fucoidan
Natural Oral Care in Dental Therapy
5
Table 1.1 Classification of natural oral care on the basis of their uses.
Part used or type of
formulation
References
Pterocarpus marsupium
Roxburgh
Stem wood
[12]
Syzygium aromaticum
Flower buds
[13]
Piper betel (Piperaceae)
Leaves
[14]
Spilathes acmella (Asteraceae)
Aerial part
[15]
Vitex negundo
Fresh leaves
[16]
Anacyclus pyrethrum
Root
[17]
Lavender (Lavandula
angustifolia Miller)
Volatile oil
[18, 19]
Citrus aurantium and Citrus
sinensis
Volatile oil
[20, 21]
Acacia arabica
Chewing stick, gum
[22, 23]
Amaranthus hybridus L.
Spinach leaf
[24]
Papain
Papain,
[25]
Pineapple
Bromelain, extract
[25, 26]
Salvadora persica
Roots
[25, 27]
Azadirachta indica
Mouthwash
[28, 29]
Aloe vera
Mouthwash
[30]
Ocimum sanctum
Mouthwash
[31]
Irimedadi oil
Polyherbal Ayurvedic
formulation
[32]
Apis
Honey
[33]
Camellia sinensis (green tea)
Catechin
[34–36]
Mangifera indica
Leaf
[37]
Garcinia mangostana L
Pericarp
[38]
Triphala
Polyherbal Ayurvedic
formulation
[39]
Propolis
Mouthwash
[40]
Uses
Source
Analgesic and local
anesthetic
Antianxiety
Whitening agent,
Antiplaque
(Continued)
6
Natural Oral Care in Dental Therapy
Table 1.1 Classification of natural oral care on the basis of their uses. (Continued)
Uses
Antiadhesion
activity
Anti-halitosis
Source
Part used or type of
formulation
References
Probiotic
Mouthwash
[41]
Calendula officinalis
Tincture
[42]
Dill
Seed oil
[43]
Turmeric
Mouthwash
[44]
Vaccinium macrocarpon
Cranberry juice
[45]
Polygonum cuspidatum
Methanol extract from
root
[46]
Andrographis paniculata,
Cassia alata, Chinese black
tea (Camellia sinensis) and
Harrisonia perforata
Ethanolic extract
[47]
Helichrysum italicum
Flowering tops
[48]
Malus domestica (Apple)
Fruit
[49]
Schinus terebinthifolius and
Croton urucurana
Hydroalcholic extract
[50]
Mushroom (Lentinus edodes)
Extract
[51]
Bauhinia variegata L. var.
variegata
Lectin
[52]
Camellia sinensis (Green tea)
Epigallocatechin-3gallate
[53]
Cinnamomum verum
Bark essential oil
[54]
Chenopodium quinoa Willd
Alkali-transformed
saponin from
quinoa husks
[55]
Bixa orellana
Seeds
[56]
Rice bran, sesame
Oil
[57]
Sasa senanensis Rehder
Leaves
[58]
Melaleuca alternifolia
Essential oil
[59]
Brassica juncea L. (mustard)
Seed (allyl
isothiocyanate)
[60]
(Continued)
Natural Oral Care in Dental Therapy
7
Table 1.1 Classification of natural oral care on the basis of their uses. (Continued)
Uses
Root canal
irrigation
Part used or type of
formulation
References
Juniperus cedrus, Hiba cedar
wood (Thujopsis dolabrata),
and Western red cedar
(Thuja plicata)
Hinokitiol
[61]
Magnolia officinalis
Bark
[62]
Curcuma zedoaria
Root
[63]
Glycyrrhiza uralensis
Licoricidin and
licorisoflavan
A isolated from Root
[64]
Panax ginseng C.A. Meyer
Root
[65]
Eucalyptus
Extract
[66]
Morinda citrifolia and Triphala
Juice
[67]
Chamomile (Matricaria
recutita L.)
Hydroalcholic extract
[68]
Apple
Vinegar
[69]
Oregano
Extract solution
[70]
Chitosan
0.2% solution
[71]
Morinda citrifolia
Fruit juice
[72]
Morinda citrifolia, Aloe Vera,
and Propolis
Juice and solution
[73]
German chamomile
(Marticaria recutita L.)
and tea tree (Melaleuca
alternifolia L.)
Extract and Oil
[74]
Aroeira-da-praia (Schinus
terebintifolius Raddi) and
the quixabeira (Syderoxylum
obtusifolium Roem & Schult)
Hydroalcoholic
extracts
[75]
Berberine
Plant alkaloid
[76]
Azadirachta indica, Morinda
citrifolia
Solution
[77]
Salvia officinalis
Extract
[78]
Source
(Continued)
8
Natural Oral Care in Dental Therapy
Table 1.1 Classification of natural oral care on the basis of their uses. (Continued)
Uses
Pulpal and dentin
repair
Storage medium
Source
Part used or type of
formulation
References
Salvadora persica
Ethanolic extract
[79]
Turmeric, Morinda citrifolia
Extract
[80]
Allium sativum
Extract
[81]
Satureja Khuzistanica Jamzad
Essential oil
[82]
Fragaria vesca (wild strawberry)
Extract
[83]
Ferula gummosa
Essential oil
[84]
Peganum harmala
Seed extract
[85]
Azadirachta indica
Ethanolic leaf extract
[86]
Allium sativum
Oil
[87]
Green propolis
Extract
[88]
Scutellaria baicalensis
Flavonoid baicalein
[89]
Panax ginseng
Ginsenoside rg1
[90]
gardenia fruit extract
Genipin
[91]
Quercetin
Flavanoids
[92]
Nigella sativa
Oil
[93]
Tobaco
Nicotine
[94]
Polyphenols found in various
plants
Epicatechin
[95]
Green tea
Extract
[96]
Coconut
Water
[97]
Thai propolis
Extract
[98]
Propolis
Extract
[99]
Probiotic
Milk
[100]
Probiotic
Yogurt (Bifidibacterium
animalis DN 173010)
[101]
Goat
Milk
[102]
Morus rubra
Fruit juice
[103]
Salvia officinalis
extract
[104]
(Continued)
Natural Oral Care in Dental Therapy
9
Table 1.1 Classification of natural oral care on the basis of their uses. (Continued)
Uses
Sealer cements
Natural
antioxidants
on the shear
bond strength of
composite Resin
Solvents
Source
Part used or type of
formulation
References
Coconut and soy
Water and milk
[105]
Capparis spinosa
Buds
[106]
Punica granatum
Juice
[107]
Green tea
Extract
[108]
Castor
Oil
[109]
Neem (Azadirachta indica) and
turmeric (Curcuma longa)
Neem leaves and
turmeric rhizomes
[110]
Aloe vera
Leaf extract
[111]
Juniperus cedrus, Hiba cedar
wood (Thujopsis dolabrata)
and Western red cedar (Thuja
plicata)
Hinokitiol-modified
calcium silicate (CS)
cement
[112]
Curcuma longa
Curcumin-loaded
mesoporous calcium
silicate
[113]
Green tea and white tea
Extract
[114]
Aloe Vera, Pomegranate Peel,
Grape Seed, Green Tea
Extract
[115]
Amla (Indian gooseberry)
Extract
[116]
Grape seed
Extract
[117]
Rosemary
Extracts
[118]
Mangosteen
Peel extract
[119]
Eucalyptus, orange, clove oil
Oil
[120]
Grapefruit, lemon
Oils
[121]
dental treatment. In the last few decades, various phytochemicals are reported in dentistry showing antimicrobial, analgesic, local anesthetic, anti-halitosis, and teeth whitening activity (Table 1.2). The chemical constituents obtained from natural resources
play a key role in dentistry. Phytochemicals like alkaloids, flavones, flavonoids, flavonols,
terpenoids, terpenes, phenols, phenolic acids, saponins, glycosides, quinone derivatives,
organosulfur compounds, alcohols, aldehydes, ketones, lectins, enzymes, and amino
acids are widely used in oral care (Table 1.3).
10
Natural Oral Care in Dental Therapy
Table 1.2 List of phytochemical reported in dental care.
S. No
Sources
Active phytoconstituents
Activity
References
1.
Aceriphyllum rossii
Aceriphyllic acid a and
3-oxoolean-12-en-27oic acid
Anticariogenic
activity
[122]
2.
Albizia myriophylla
Lupinifolin
Anticariogenic
activity
[123]
3.
Allium sativum
Allicin, diallyl sulfide
Antimicrobial
activity
[124, 125]
4.
Bursera morelensis
Ramirez
Α-pinene, γ-terpinene
Antifungal
[126]
5.
Cymbopogon nardus
Citronellal
Antifungal
[127]
6.
Dryopteris
crassirhizoma
Linoleic acid
Antibiofilm
activity
[128]
7.
Diospyros lycioides
Juglone
Antibacterial
[129]
8.
Erythrina variegata
Erycristagallin
Antibacterial
property
[130]
9.
Eucalyptus globules
Macrocarpals a, b, and c
Antibacterial
[131]
10.
Garcinia kola Heckel
(Clusiaceae)
Biflavonoid gb1
Antibacterial
[132]
11.
Gnetum gnemon L
Resveratrol
Osteoclast
activity
[133]
12.
Mentha piperita
Menthol
Antimicrobial
[134]
13.
Origanum onites
Carvacrol and thymol
Antimicrobial
[135]
14.
Scrophularia striata
Gallic acid, quercetin,
and apigenin
Antimicrobial
[136]
15.
Rumex acetosa L
Procyanidin-b2-di-gallate
Antimicrobial
[137]
16.
Flavonoids present
in many fruits and
vegetables
Quercetin and kaemferol
Antimicrobial
[138]
17.
Nidus vespae
(honeycomb)
Quercetin and
kaempferol
Antimicrobial
[139]
(Continued)
Natural Oral Care in Dental Therapy
11
Table 1.2 List of phytochemical reported in dental care. (Continued)
S. No
Sources
Active phytoconstituents
Activity
References
18.
Dodonaea viscosa var.
angustifolia
5,6,8-trihydroxy-7methoxy-2-(4methoxyphenyl)-4hchromen-4-one
Anti-S. mutans,
antibiofilm,
and antiacidogenic
activity
[140]
19.
Curcuma longa
Curcumin
Antibacterial
[141, 142]
20.
Tea
Epigallocatechin-3-gallate
Antibiofilm
[143, 144]
21.
Galla rhois
Methyl gallate (mg) and
gallic acid (ga)
Antimicrobial
[145]
22.
Grapes
Ethyl gallate
Anticaries agent
[146]
23.
Garcinia mangostana L
α-Mangostin
Antimicrobial
[147]
24.
Magnolia officinalis
Magnolol and honokiol
Antimicrobial
[148, 149]
25.
Myristica fragrans
Macelignan
Anticariogenic
activity,
antibiofilm
[150, 151]
26.
Mikania glomerata
Ent-kaurenoic acid
Antimicrobial
[152, 153]
27.
Morus alba
Kuwanon g
Antimicrobial
activity
[154]
28.
Clove, nutmeg,
cinnamon
Eugenol
Local anesthetic,
analgesia
[155–157]
29.
Trachyspermum ammi
4as, 5r, 8as) 5,
8a-di-1-propyloctahydronaphthalen1-(2h)-one
Antibiofilm
activity
[158]
30.
Theobroma cacao (cacao
bean husk)
Epicatechins
Antibacterial
activity
[159]
31.
Ginkgo biloba
Ginkgoneolic acid
Antimicrobial
activity
[160]
32.
Psidium guajava Linn.
Quercetin-3-o-alphal-arabinopyranoside
(guaijaverin)
Antiplaque
agent
[161]
(Continued)
12
Natural Oral Care in Dental Therapy
Table 1.2 List of phytochemical reported in dental care. (Continued)
S. No
Sources
Active phytoconstituents
Activity
References
33.
Rabdosia trichocarpa
Trichoranin
Antibacterial
activity
[162]
34.
Rhus coriaria L.
Methyl gallate
Antibiofilm
activity
[163]
35.
Rosmarinus officinalis
Carnosic acid and
carnosol
Antimicrobial
activity
[164]
36.
Glycyrrhiza glabra
Glycyrrhetinic acid,
disodium succinoyl
glycyrrhetinate
Antimicrobial
activity
[165, 166]
37.
Glycyrrhiza uralensis
Icoricidin and
licorisoflavan A
Antibacterial
activity
[167]
38.
Aralia cachemirica L.
(Araliaceae)
4-epi-pimaric acid
Antimicrobial
activity
[168]
39.
Piper betle
Hydroxychavicol
Antimicrobial
activity
[169]
40.
Piper cubeba
(−)-Cubebin
Antimicrobial
activity
[170]
41.
Polyalthia longifolia var.
pendula (Linn.)
16-Oxo-cleroda-3, 13(14)
e-diene-15 oic acid,
and kolavenic acid
Antimicrobial
activity
[171]
42.
Propolis
Neovestitol-vestitol,
apigenin, and
tt-farnesol
Antimicrobial
activity
[172, 173]
43.
Fruits of Rheedia
brasiliensis
7-Epiclusianone
Antimicrobial
activity
[174]
44.
Iostephane heterophylla
Ent-trachyloban-19-oic
acid
Antibiofilm
activity
[175]
45.
Symplocos racemosa
Symploquinones a-c
Antibiofilm
activity
[176]
46.
Swartzia polyphylla
Dihydrobiochanin
a, ferreirin and
darbergioidin, and
dihydrocajanin
Antibacterial
activity
[177]
47.
Polygonum cuspidatum
Emodin
Antibacterial
activity
[178]
(Continued)
Natural Oral Care in Dental Therapy
13
Table 1.2 List of phytochemical reported in dental care. (Continued)
S. No
Sources
Active phytoconstituents
Activity
References
48.
Croton nepetaefolius
Casbane diterpene
Antimicrobial
activity
[179]
49.
Viguiera arenaria
Ent-pimara-8(14),15dien-19-oic acid
Antimicrobial
activity
[180]
50.
Mikania glomerata
Sprengel
Ent-kaurenoic acid
Antibacterial
activity
[181]
51.
Vaccinium
macrocarpon
Cranberry a-type
proanthocyanidins and
flavonols
Antibacterial
activity
[182]
52.
Curcuma xanthorrhizha
(Javanese turmeric)
Xanthorrrhizol
Antibacterial
activity
[183]
53.
Ipecacuanha, cinchona
Emetine, quinine
Antibacterial
activity
[184]
54.
Corn husks or sugarcane straw
Xylitol
Antibacterial
activity
[185]
55.
Birch bark
Betulin
Antiinflammatory
activity
[186, 187]
56.
Berberis vulgaris
Berberine
Slow periodontal
degradation
[188]
57.
Salvadora persica
Benzyl isothiocyanate
Anti-Gramnegative
bacteria
[189]
58.
Kaempferia pandurata
Roxb.
Panduratin A,
isopanduratin A
Antimicrobial
[190, 191]
59.
Syzygium aromaticum
(L.) Merr. & L. M.
Perry
Eugenol
Antibiofilm
activity
[192]
60.
Copaifera reticulata
(−)-Copalic acid
Antimicrobial
activity
[193]
61.
Melaleuca alternifolia
(tea tree )
Alpha-bisabolol
Antibiofilm
activity
[194]
62.
Eucalyptus
1,8-cineole
Antibiofilm
activity
[195]
Q3
14
Natural Oral Care in Dental Therapy
Table 1.3 Chemical classification of natural oral care.
Category
Examples
Alkaloids
Atropine, morphine, sanguinarine, chelerythrine, colchicines, nicotine,
pilocarpine, cotinine, theobromine, sanguinarine, scopolamine, cocaine,
vincristine, berberine chloride, oxyacanthine sulfate, harmine, vasicine,
Berberine, Salvadorine, Piperine, Emetine, quinine
Flavones,
flavonoids, and
flavonols
Quercetrin, naringenin, proanthocyanidin, myricetin, apigenin, luteolin,
fisetin, catechin, epicatechin, pelargonidin, myricetin, kaempferol,
hesperidin, catechins, epicatechin, gunistein, daidezin, gallocatechin,
cyanidin, Icoricidin, licorisoflavan A, Kenferaido, galangin,
isorhamnetin, rhamnetin, 3,7-dihydroxy-5-methoxy flavanone,
2,5-dihydroxy-7-methoxy flavanones Bruno, 3-methyl quercetin,
8-methyl kaempferol, Dihydrobiochanin a, ferreirin and darbergioidin,
dihydrocajanin, pinobanksin, pinobanksin 3-acetate, Lupinifolin,
Biflavonoid gb1, Procyanidin-b2-di-gallate, pinobanksin 7-methyl ether,
pinocembrin, sakuranetin, isosakuranetin, Pinosutorobin, trihydroxymethoxy flavanone, tetrahydroxy flavanones, tetrahydroxy flavone,
chrysin, acacetin, baicalein, tectonics chrysin, kaempferol, Erumanin,
3,5,7-trihydroxy-4 -methoxy flavanols, 5,6,7-trihydroxy-3,4 -dimethoxy
flavone, 5,6,8-trihydroxy-7-methoxy-2-(4-methoxyphenyl)-4hchromen-4-one, 4as, 5r, 8as) 5,8a-di-1-propyl-octahydronaphthalen-1(2h)-one, Cranberry a-type proanthocyanidins, flavonols
Terpenoid
Aceriphyllic acid, Nimbidin, 1,8-cineole, ursolic acid, oleanolic
acid, terpineol, nerolidol, bisabolol, melliferone, moronic acid,
β-caryophyllene, santatol, abietic acid, lanosterol, cupressic acid,
agathalic acid, communic acid, methyl isocupressate, tremetone,
viscidone, Erycristagallin, Macrocarpals, ledol, guajol, humulene,
bulnesol, Glycyrrhetinic acid, viscidone, betuletol, anwuweizonic acid,
thymol, Xanthorrrhizol, betulonic acid, α-copaene, ent-kaurenoic acid,
β-selinene, α-elemene, calamenene, β-amyrine, amyrine, α-muurolene,
γ-muurolene, dehydroabietic acid, β-eudesmol, syringaldehyde,
imbricatoloic acid, tt-famesol, Oridonin, Ursolic acid, Citronellal,
16-oxo-cleroda-3, 13(14) e-diene-15 oic acid and kolavenic acid, Enttrachyloban-19-oic acid, Ent-pimara-8(14),15-dien-19-oic acid, Entkaurenoic acid
Terpenes
Casbane diterpene, Betulin, alpha-pinene, menthol, Copalic acid,
Alpha-bisabolol
Phenols and
phenolic acids
Eugenol, Epigallocatechin-3 gallate, gallic acid, Α-mangostin, citric
acid, Curcumin, Magnolol, Carvacrol, (6)-gingerol, Hydroxychavicol,
(6)-shogaol, Resveratrol, honokiol, Methyl gallate, Ethyl gallate,
Macelignan, Ginkgoneolic acid, 4-epi-pimaric acid, (−)-Cubebin
Saponins
Ginsenoside Rg1, ginsenoside Rh2, Glycyrrhizin, Buddlejasaponin IV,
Diosgeninlactoside
(Continued)
Natural Oral Care in Dental Therapy
15
Table 1.3 Chemical classification of natural oral care. (Continued)
Category
Examples
Glycoside
Fomitoside-K, Divaricoside, rubusoside, C-xylopyranoside, stevioside,
rutin, Quercetin-3-o-alpha-l-arabinopyranoside
Quinone
derivatives
aloe emodin, Juglone, Symploquinones a-c, Emodin
Organosulfur
compound
Allicin, diallyl sulfide, allyl isothiocyanate, Benzyl Isothiocyanate,
phenethyl isothiocyanate, allyl isothiocyanate
Alcohol
Xylitol
Aldehyde
Cinnamaldehyde
Ketones
Panduratin A, isopanduratin A, 7-epiclusianone, Panduratin A,
isopanduratin A
Lectins
Labramin, aloctin A, lectins from Canavaliaensi formis (ConA), Canavalia
brasiliensis (ConBr), Canavalia maritima (ConM), Canavalia gladiata
(CGL), and Canavalia boliviana (ConBol), Cratylia floribunda
(CFL), Vatairea macrocarpa (VML), Bauhinia bauhinioides (BBL),
Bryothamnion seaforthii (BSL), and Hypnea musciformis (HML)
Enzymes
Papain and bromelain
Amino acids
Arginine, Caseine
1.2 Safety of Natural Oral Care
Herbal medicines or natural products are generally considered safe. Clinical studies usually
assess the efficacy of products containing natural products. There are a few studies done on
the safety and possible side effects of such products. Oral administration of clove oil developed urinary abnormalities, central nervous system depression, and a large anion-gap acidosis in an infant [9]. Neem oil in adults causes metabolic acidosis, vomiting, seizures, and
toxic encephalopathy [10]. Repeated sesame oil pulling for several months caused lipoid
pneumonia [11]. More safety study is needed when used in combination with allopathic
drugs.
1.3 Advantage of Natural Oral Care
• Development of antimicrobial resistant strains is increasing using synthetic
chemicals. So natural antibacterial substances are as useful as alternative
antimicrobials in oral care.
• Current synthetic chemicals such as chlorhexidine, povidone iodine, triclosan fluoride, cetylpyridinium, zinc citrate, and sodium lauryl sulfate used
in dentifrices and mouthrinses as antibacterial can be quite damaging to the
16
Natural Oral Care in Dental Therapy
gums, teeth, and mouth. So their long-term use is limited. So natural oral
care formulation is free from such side effect.
• Use of traditional tooth cleaning methods includes efficacy, safety low cost,
popularity, and availability.
• Natural oral care is a safe option to kids, pregnant women, blood pressure
patients, diabetics, and people with dry mouth.
1.4 Limitations of Natural Oral Care
•
•
•
•
•
•
Low worldwide availability
Standardization
Some plants are useful when used in fresh form
Complete toxic study data are not available
Data of interaction with allopathy drugs are not available
Very slow in curing the disease
1.5 Future Prospects of Natural Oral Care
India is juvenile in handling dental problems. It is still a common problem worldwide.
Dental caries and periodontal diseases can be treated with chemicals and allopatic drugs.
The common side effects associated with them are nausea, vomiting, diarrhea, or teeth
staining. The patient’s compatibility with the chemical uses is also not found to be appropriate. The dental problems are well taken using drugs of herbal origin. The utmost
requirement in industries is to develop a safe and effective formulation. Prolonged use of
synthetic chemical agents produces side effects, and for financial considerations, there is
a need for natural agents that are effective, safe, and economical. The herbal drugs may
be used externally as ointment, pastes, plasters, and poultices or internally as syrups, suspensions, or pills. Ancient techniques like oil pulling therapy, chewing stick, and aqueous
herbal extract are an affordable option for its oral health benefits in rural communities.
As verified by the examples, there is extensive proof that plant products have the potential
to be used as preventative or treatment therapies for oral diseases. The effective advantages with herbal products are cheap, easy availability, greater shelf life, minimal toxicity,
and lack of microbial resistance, which is the major advantage with herbal drugs. The
drugs used in oral care for suppressing inflammation, may have antibacterial, antifungal,
and analgesic activities. They can be recommended in gingivitis, mucositis, or any infection of fungal or bacterial origin. The active chemical constituents, which are found to be
effective in dental caries, are flavanoids, phenolic acids, resins, triterpenes, carotenoids,
or tannins. These active constituents are obtained from drugs, for example, amla, lemon,
clove, neem, tulsi, etc. The ethnopharmacology and reporting of clinical data, systems
with chemical and pharmacological characterization of extracts from promising sources
will lead to new product development for dentistry. Molecules such as eugenol, quercitin, and kaempeferol were isolated from plants and have dental therapeutic potential.
After development with phytochemistry and formulation technologies, and in combination with other active ingredients, a novel formulation should be made. The use of
Natural Oral Care in Dental Therapy
17
strandardized herbal formulation helps in pharmacological activity and prevents from
adulteration. It can be concluded that these herbal drugs must be included in everyday
life so that the dental problem can be resolved. These drugs may be used in isolation
or combination. These will surely suppress the growth of oral pathogens, minimize the
development of dental plaque, and also help in curing the symptoms of oral diseases. The
minimal toxicity and minimal cost of these herbal drugs should be promoted for further
investigation. This may come with a noble drug leading to a better understanding of
traditional Asian medicines and their uses for oral health. However, a health well-wisher
should take this herculean task to confirm that individuals must promote herbal medicines to protect public health.
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2
Herbal Products for Oral Hygiene: An
Overview of Their Biological Activities
Ummuhan Sebnem Harput
*
Independent Researcher, Ankara, Turkey
Abstract
Oral hygiene plays a crucial role in the prevention of oral diseases, including periodontitis, tooth decay,
and oral candidiasis. In addition, many scientific studies show a relationship between oral health and
cardiovascular diseases, diabetes, and even death. In order to prevent caries formation and periodontal
diseases, effective oral hygiene should be performed and plaques should be removed, plaque formation
should be prevented, and strains should be removed. Patients and dentists are faced with different oral
hygiene products containing active and inactive ingredients. Although chemical-based products are
good at oral hygiene, there are many adverse effects of dental hygiene products, which are sold in the
market. Effective usage of toothbrush, floss, or rinse is found very important for making oral hygiene
even without using any chemicals. In addition, although popular herbal products have helped to control dental plaque and gingivitis, their safety and efficacy is not researched in detail. Herbal products
may offer significant advantages over the chemical ones with less side effects and high antimicrobial
potential. In addition, people are aware of the effects of herbal products for oral care, and their interest
in these products has increased recently. Traditional herbal-based treatments provide reduced adverse
reactions of chemical counterparts such as resistance to antibiotics, corrosion, or staining of teeth.
Herbal products such as clove and clove oil, coconut oil, pomegranate, green tea, Salvadora persica
(meswak), Aloe vera, Acacia arabica, Melaleuca alternifolia (tea tree), Azadirahta indica (neem), and
licorice are used to promote oral hygiene, and their inhibitory effect on biofilm formation is shown in
different studies. According to bioactivity studies on these species, antibacterial, anti-inflammatory,
anticariogenic, and astringent properties were observed for their components and/or extracts. If such
herbal products can be formulated effectively, this may lead to an improvement in the general dental
health of the population. Summarized here are such natural products, which may be used effectively in
the commercial formulations and/or personal product.
Keywords: Herbal medicine, oral hygiene, oral hygiene products, dental plaque
2.1 Introduction
There is an increasing public awareness on personal oral hygiene. Apart from toothbrushes
and toothpastes, toothpowder, mouthrinses, and similar products are also widely used in
Email: sharput@gmail.com
Durgesh Nandini Chauhan, Prabhu Raj Singh, Kamal Shah, and Nagendra Singh Chauhan (eds.)
Natural Oral Care in Dental Therapy, (31–44) © 2020 Scrivener Publishing LLC
31
32 Natural Oral Care in Dental Therapy
the population. People brush and rinse their teeth to feel fresh, to avoid bad breath, dental
caries, oral diseases, and to have a nice smile. Effective oral care is important for all individuals, especially for kids, pregnant women, and those who have an immune system deficiency, or undergoing chemotherapeutic or radiation therapy. In addition, many scientific
studies show a relationship between oral health and cardiovascular diseases, diabetes, and
even death. In order to prevent caries formation and periodontal diseases, effective oral
hygiene should be performed and plaques should be removed, plaque formation should be
prevented, and strains should be removed [1, 2]. The World Health Organization (WHO) is
also promoting oral hygiene advice to be included in the school curriculum. If oral hygiene
habit is neglected for the school ages, it will cause serious health problems in the future.
Oral infections, periodontal disease, and dental caries are occurring very common all
around the world. Effective oral hygiene prevents oral infections and diseases. Antibiotics,
fluoride, and chlorhexidine derivatives are used successfully as oral hygiene products
against oral diseases including infections and caries; however, long-term overuse of these
chemical-based oral hygiene products caused some oral or systemic adverse reactions [3].
Dental treatments are expensive and usually not covered by health insurance services.
Abrasives, preservatives, surfactants, sweeteners, or colorants found in the composition
of dental products can cause not only corrosion on teeth but also other health problems.
Their effectiveness is still questionable. Hence, there is an increasing demand for the use
of herbal products and treatments as alternatives to chemical treatments for maintaining
oral health [4].
Numerous different products or their mixture can be used for oral hygiene throughout
the centuries. These old formulations had the potential oral or systemic side effects because
of their toxic constituents such as sulfuric acid, mercuric perchloride, carbolic acid, and
formaldehyde. With the recognition of these toxic effects, researches for new products have
increased rapidly, and more reliable products have emerged over the years [5].
In recent years, herbal products in oral care, which are widely used in traditional medicine, have attracted the attention of researchers looking for a safer and more effective oral
hygiene product. Traditionally, herbal products such as clove and clove oil, coconut oil,
pomegranate, green tea, Salvadora persica (meswak), Aloe vera, and Acacia arabica are used
to promote oral hygiene. Antibacterial, anti-inflammatory, anticariogenic, and astringent
compounds are mostly isolated from these species [6, 7]. For example, as a result of the
evaluation of traditional usage and scientific evidences of the extract of Salvadora persica,
it has been included in many oral rinse and toothpaste products with the evidence of safety
and effectiveness data [8].
Since herbal products for oral hygiene can be purchased OTC in many countries, they
began to attract an increasing number of consumers who are looking for an alternative
product. However, it is difficult to find a reliable, safe, and effective herbal oral hygiene
product in the market. More research is needed to determine their effectiveness and safety
[9]. There has been no comprehensive review summarizing the pharmacological properties,
phytochemical characteristics, and appropriate usages of herbal oral hygiene products for
researchers and for the producers who want to develop new commercial products. In this
study, we will discuss prominent plant extracts and phytochemicals, which can be used as
a safe and effective oral hygiene product. Clinical studies that have investigated the quality,
efficacy, and safety of such herbal products and their phytochemical composition and pharmacological properties will also be described.
Herbal Products for Oral Hygiene 33
2.2 Oral Hygiene and Current Treatments
The mouth is inhabited by millions of bacteria. While we cannot sterilize the mouth, we
should minimize bacterial panacea for preventing tooth decay. The most important thing
here is inhibition to form organized bacterial colonies, which are referred to as “dental
plaque”. Dental plaque is composed of over 500 bacterial species [10]. Generally, inadequate oral hygiene habits cause oral health problems such as caries and periodontal disease. Similarly, periodontal diseases are chronic infections caused by bacteria existing at the
dental plaque. Bacterial invasion and colonies are the causes of inflammation and bleeding
gums in the oral cavity. If it is not treated successfully, it leads to tissue destruction, tooth
mobility, and even tooth loss. In the final stage, periodontal bacteria can enter the blood
stream and may cause systemic reactions such as increased risk of heart disease, stroke, and
diabetes. Good oral hygiene is very important in preventing and controlling of the above
risks and dental decay [11]. Generally, oral hygiene is provided by daily tooth brushing
with toothpaste. The possible forms of action of these agents can be discussed under two
headings: antiplaque and antigingivitis. The antiplaque agents can be further subdivided
as antiadhesives and antimicrobials. Chemotherapeutic agents used for plaque removal
include anticalculus agents such as pyrophosphate, antibacterials such as Triclosan and
chlorhexidine, anticaries agents such as fluoride, whitening agents such as alumina, and
desensitizing agents such as strontium chloride [12, 13].
Some of the commercially available toothpastes contain plant products. The addition of
peppermint, cloves, aniseed, and recently tea tree oil (Melaleuca alternifolia), aloe vera gel,
olive leaf, and neem leaf extracts enhance the antimicrobial activity of the toothpastes [3].
For example, the extract of Salvadora persica incorporated into herbal toothpastes against
dental plaque bacteria is well documented [14]. Xylitol and stevia extract, which are natural
sweeteners, are used in some toothpaste formulations instead of fluoride to control plaque,
as well as to strengthen the teeth and gums. Recently, commercially available oral preparations can be available, which contain several plant ingredients including green tea, aloe
vera, garlic juice, thymol, eucalyptol, licorice, and rooibos [3, 15, 16].
Mouthrinses are also used together with mechanical or chemical oral hygiene products
in order to prevent different kinds of oral diseases, treat high caries risk and infection,
reduce inflammation, relieve pain, and reduce halitosis. It is one of the alternative methods
to mechanical plaque control. Chlorhexidine is the main ingredient, which has much of the
desirable characteristics of antiplaque mouthrinse; however, it is also responsible for major
side effects, especially the extrinsic staining of hard and soft tissues. Similarly, the long-term
use of ethanol-containing mouthrinses should be discouraged in patients with a high risk of
caries [17, 18]. Hence, safety of these products has not yet been proven, and there is a need
for long-term clinical trials to find an effective and safer alternative to chlorhexidine with
all the good properties and without its side effects.
2.3 Plants Traditionally Used in Oral Hygiene
The use of herbal products for the protection of oral health and treatment of oral diseases
comes from the very old days of the world. A well-known example, Salvadora persica L.
(miswak or siwak), is the most common traditional source of the material for oral hygiene.
34 Natural Oral Care in Dental Therapy
Since Islam has emphasized the usage of miswak for oral hygiene, the use of Miswak is
widespread in Islamic countries for basic oral hygiene. The antibacterial effect of Salvadora
persica extracts against bacteria in dental plaque is well documented throughout the world
[8, 19–21]. Benzyl isothiocyanate and its derivatives were identified as the major antibacterial component, and their amount reflects the efficacy of the miswak [21]. It is proposed
by the WHO, and it is encouraged to do further research for its biological activities on oral
health [8, 14].
Green tea, the leaves of Camellia sinensis is a popular drink that has a beneficial
physiological effect. It is widely consumed all over the world and proven to have antioxidant and antibacterial effects against bacterial colony of dental plaque. It has been
found that green tea polyphenols can eliminate halitosis by modifying the odorant sulfur components. Oxidative stress and inflammation in the oral cavity, due to heavy
cigarette smoking and alcohol consumption, also decreased in the presence of green
tea polyphenols [6, 14, 22].
There are many different plant species used for periodontal disease and oral hygiene in
India. The dried powders of Acacia arabica (bark), Terminalia chebula (fruits), Terminalia
bellerica (fruits), and Emblica officinalis have been used in their traditional tooth formulas for more than a century [23]. Rasingam et al. reported on the traditional herbal tooth
sticks used by the inhabitants of Andaman and Nicobar Island in India [24]. Among these
species, neem (Azadirachta indica), which is widely used as chewing stick throughout the
world, is a native of India and is cultivated in all parts of the subcontinent because of its
medicinal properties. It was reported that every part of the neem tree, such as branches,
twigs, bark, and oil, was used for oral health in India, for centuries [6, 24, 25]. It is one of
the traditional dental care practices in India to brush with neem and mango branches and
chew the neem leaves and seeds after the meals. The stems of Azadirachta indica have antiinflammatory and antimicrobial activities due to the presence of substances such as nimbin
and nimbidine as phytochemicals. In case of mango twigs (Mangifera indica), mangiferin,
which is the natural C-glucoside xanthone, has been reported in various parts of the plant
such as leaves, fruits, stem, bark, and roots. Antioxidant, radioprotective, immunomodulatory, antitumor, antiallergic, anti-inflammatory, antidiabetic, and antimicrobial properties of mangiferin are reported in many studies. It has also therapeutic potential in both
the prevention and treatment of periodontitis [26, 27]. Different Artemisia (wormwood)
species are used traditionally because of its medicinal properties. For example, Artemisia
absynthium, Artemisia herba alba, and Artemisia siberia extracts can be used in cosmetic
and toiletry products such as toothpastes, which not only cleans the teeth but also prevents
decay, treats bad breath, and protects the oral hygiene [28, 29].
Another important method of traditional oral hygiene is oil pulling. which has been
applied for a long time as a traditional folk medicine in India. Recently, people around the
world are increasingly interested in this method, which is offering oral health benefits and
oral hygiene. Based on current research, it was found that, when administered correctly
and regularly, oil pulling improved oral hygiene. However, oil pulling does not replace dental treatments and is currently not recommended by the American Dental Association.
According to the latest data, it can be safely used with brushing teeth and flossing as well as
help maintain good oral hygiene and health [30, 31].
Herbal Products for Oral Hygiene 35
2.4 Clinically-Studied Plant Products for Oral Hygiene
Because of the side effects of routinely used chemical-based dental hygiene products such as
toothpastes, dentifrices, and mouthwash, researchers are trying to find herbal products that
do not contain any chemical ingredients. Consumers often prefer herbal products rather
than the products that contain chemical ingredients. Recently, clinical studies on efficacy
and safety of plant extracts and herbal-derived dental products were increased to support
their usage in oral care [32]. Some of the important clinical studies are summarized below.
For example, Srinivasa et al. evaluated the plaque and the gingival status of children
brushing with commercially available herbal dentifrice (containing sodium monofluorophosphate and chamomile, eucalyptus, myrrh, sage as active ingredients) in comparison with non-herbal dentifrice (sodium monofluorophosphate and triclosan as active
ingredients) for a period of 21 days [33]. Although they found no significant difference
between the two groups, the herbal group showed a significant reduction in gingival
bleeding and inflammation compared to the non-herbal group. It could be because of the
anti-inflammatory and astringent properties of the herbal constituents in the herbal dentifrice. Therefore, the tested herbal dentifrice can be considered as an alternative product
to protect gingival health compared with the commercial one [33].
In addition to their effect on dental health, taste, smell, and the other flavor characteristics of the herbal dental products are very important for the consumer or patients to use it
tastefully. The antimicrobial effect of Melaleuca alternifolia (tea tree) containing dental gel
was studied in 34 orthodontic patients compared with the commercial toothpaste Colgate
Total. While Melaleuca gel was found to be more effective in decreasing the dental biofilm
and the number of bacterial colonies, it was not as good as Colgate Total regarding the taste,
smell, and the other flavor characteristics. They found that Melaleuca gel is efficient in the
control of bacterial growth but needs good formulation for improvement in taste and first
sensation [34].
Plaque and gingivitis reduction were assessed with the toothpaste containing Azadirahta
indica (neem) and the commercial toothpaste comparatively in randomized, double blind
clinical trial. In this study, regular use of neem-containing toothpaste provided a significant reduction in plaque formation and improved the gingival health of the participants. It
could be due to the antibacterial and anti-inflammatory effects of neem. This result indicated that regular brushing with neem toothpaste is important for the maintenance of good
oral hygiene and improvement of oral health [35]. Similarly, the effect of neem and mango
mouthwashes on oral health was assessed by Sharma et al. [26]. Three groups of children
were tested for 21 days for their gingival and plaque conditions with neem, mango, and
chlorhexidine mouthwash. According to the above study, the tested three mouthwashes
have antiplaque and antigingivitis effect. They found that while clorhexidine and neem have
equivalent efficacy in plaque reduction, chlorhexidine has superior antigingivitis properties. This study provided enough data to show that neem- and mango-based mouthwashes
have a beneficial effect on oral health [26]. In another study, herbal dentifrice containing
Macleya cordata and Prunella vulgaris was investigated for the effectiveness of controlling
gingivitis in a double-blind, placebo-controlled clinical study. The extract was found to
be effective in the control of gingivitis, while it did not show any antiplaque effect. It was
36 Natural Oral Care in Dental Therapy
concluded that the tested herbal dentifrice has a significant anti-inflammatory effect and
can be used in the conventional dentifrice formulations [36].
Recently, considerable researches have been conducted on commercial mouthrinses
and toothpastes containing herbal extracts. Commercial herbal toothpaste Paradontax,
which contains sodium bicarbonate, sodium fluoride, and herbal ingredients including chamomile, echinacea, sage, myrrh, rhatany, and peppermint oil was evaluated in
a double-blind clinical trial for the reduction of plaque and gingivitis. It was found that
Paradontax did not show significant clinical advantage over the conventional toothpaste
with fluoride. This result indicated that commercial herbal toothpastes should be evaluated properly for their efficacy and advantage comparing the conventional toothpastes
[37]. Similarly, the efficacy of Paradontax was also evaluated on the reduction of plaque
and gingivitis in comparison to the dentifrice with triclosan and fluoride for 28 days.
While a significant reduction was observed in the plaque formation and gingivitis in
both groups, no significant difference was found between the two groups. The authors
concluded that both toothpastes were effective in reducing dental plaque and gingivitis rate in subjects with gingivitis [38]. The anti-inflammatory effect of Paradontax was
assessed comparatively with Colgate herbal toothpaste, which contains calcium carbonate, chamomile, sage, myrrh, eucalyptus, and sodium monoflurophosphate in plaque and
gingival inflammation. In this study, both formulations reduced plaque formation levels
and gingival inflammation. However, Paradontax did not show any additional benefits
over Colgate herbal toothpaste [39].
In another study, ayurvedic dental cream was evaluated in comparison to fluoride dental cream for efficacy and safety in a randomized double-blind study. Herbal dental cream
consists of different ayurvedic plant species such as powders of Ajamoda satva, Vaikranta
bhasma, and Azadirachta indica; and extracts of Zanthoxylum alatum, Punica granatum,
Acacia arabica, Vitex negundo, Embelia ribes, and Triphala. While significant protection
was observed in both groups, their efficacy is not significantly different from each other.
According to this result, the ayurvedic dental cream is as safe and effective as that of fluoride dental cream, but it is not superior to the prevention and management of dental plaque
formation [40]. Another ayurvedic toothpaste containing herbal ingredients such as the
extracts of Acacia chundra, Adhatoda vasica, Mimusops elengi, Piper nigrum, Pongamia pinnata, Quercus infectoria, Syzygium aromaticum, Terminalia chebula, and Zingiber officinale
was tested for its efficacy on improving gingival health, oral hygiene, and salivary microbial
flora. They found statistically significant reductions on gingival bleeding, salivary anaerobic
bacterial counts, and better oral hygiene, while the placebo group did not show any significant improvement in oral health conditions [7]. The above studies show that herbs, which
are used traditionally in oral care, are important sources of dental hygiene products, and
further researches are needed to clarify the mechanism of action of each herb included in
these products.
Mouthwashes or rinses are also important oral hygiene products and are recently
very popular in western societies. The efficacy of the mouthwash containing an extract
of Salvadora persica, which is the most important herbal product for oral hygiene was
investigated in a double-blind, cross-over trial for a 3-week period. Although PersicaTM
mouthwash increased gingival health and lowered cariogenic bacterial transport rate,
the placebo also significantly improved gingival health [41]. Similarly, the antiplaque
effects of S. persica and 0.2% chlorhexidine rinse were compared by Gazi et al., and they
Herbal Products for Oral Hygiene 37
found that chlorhexidine rinse was better than S. persica extract in inhibiting plaque
formation [42]. On the other hand, Rahmani et al. also assessed the efficacy of mounthrinses containing S. persica and chlorhexidine on plaque formation; they found a
comparable plaque inhibition by both rinses [43, 44]. As a result of the above studies,
S. persica-containing herbal mouthrinses have provided good oral hygiene and plaque
inhibitory potential, but they are not as efficacious as chlorhexidine in preventing bacterial plaque formation.
Herbal oral rinse containing the extracts of echinacea, Hydrastis canadensis, calendula, aloe, Sanguinaria canadensis, grapefruit seed, cinnamon and spearmint oil, and
peppermint oil was also tested in comparison with 0.12% chlorhexidine oral rinse. The
effects of herbal rinse on restoring gingival health status were not statistically greater
than those of the placebo. Chlorhexidine is more efficient than herbal rinse in reducing
the clinical indicators of gingivitis when compared to the placebo. Therefore, individuals who are looking for a natural, sugar-free, and non-alcohol mouth rinse should be
advised that there is still a need for researches to support the effectiveness of herbal oral
rinses [45].
Licorice is one of the important traditional herbs used for different physiological conditions and as a food ingredient throughout the world. The effect of different licorice preparations on dental problems was evaluated by different authors. Recent researches suggest
that licorice extracts and its phytochemicals have beneficial effects in oral hygiene and
oral diseases. These effects have been attributed to the antiadherence, antimicrobial, and
anti-inflammatory properties of its constituents. However, glycyrrhizin, which is one of
the important components of licorice, is converted to glycyrrhetic acid in the human intestine and can induce severe hypertension and hypokalemia in the body. Therefore, licorice
extract without glycyrrhizin should be preferred for use in order to prevent the side effects
of licorice [46, 47]. In vitro studies have demonstrated the potential of licorice and its bioactive constituents to treat oral disease. On the other hand, clinical trials have generally
inconsistent results. Therefore, oral hygiene products containing licorice root extracts and
constituents need to be further investigated to verify the beneficial effects observed in in
vitro experiments [46].
Licorice was also used as an herbal lollipop and was examined to investigate its effect
on Streptococcus mutans bacteria, which cause dental caries. It was found that there was a
reduction in the growth of S. mutans in the oral cavity with consumption of more lollipops
during the experiment period [48]. Clinical studies have also shown that administration of
licorice lollipop leads to reduction in dental biofilm and the number of bacterial colonies
in the oral cavity among the tested individuals [49, 50]. Extracts of licorice, particularly
when formulated as candy, lollipop, or similar others indicated significant inhibition of
the formation of dental caries of human subjects. These studies show that different licorice
products can be used in oral hygiene products to prevent gingival diseases and improve oral
health [51].
2.5 In Vitro-Studied Herbal Products for Oral Hygiene
In vitro studied plant products for oral hygiene are summarized below (Table 2.1).
Tested herbal product
Method
Result
Conclusion
Phytochemicals
Ref
Leaf-bud extracts
of Populusnigra,
P. x berolinensis,
P. lasiocarpa
Anti-inflammatory activity
in gingival fibroblasts
P. X berolinensis is
effective
Useful for oral hygiene
and in the treatment
of gingivitis,
periodontitis
Flavanons: pinocembrin,
pinostrobin
[52]
Artemisia sieberi
essential oil
Antimicrobial activity
against Gram +/−
bacteria, yeast and fungi
Active
It can be used in
toothpastes because
of antibacterial effect
against S. mutans
Dried extract of Acacia
arabica (bark),
Terminalia chebula
(fruits), Terminalia
bellerica (fruits),
Emblica officinalis
(fruits)
Antimicrobial, biofilm
disruption and
anticaries effect against
cariogenic bacteria
Inhibitory effects
of cariogenic
microorganisms
and S. mutants
biofilm formation
Useful resource of
anticariogenic dental
products
Combination of
Salvadora persica and
green tea extracts
Effect on dental biofilm
formation
Synergistic
antibacterial and
antiadherence
effects
Useful active agent for
oral care products.
, thujone, camphor
[28]
[23]
Green tea: catechins and
flavonoids; S. persica:
trimethylamine,
salvadorine,
thiocyanate, tannins,
nitrate, sulfate
[14]
(Continued)
38 Natural Oral Care in Dental Therapy
Table 2.1 In vitro studied plant products for oral hygiene.
Table 2.1 In vitro studied plant products for oral hygiene. (Continued)
Method
Result
Conclusion
Phytochemicals
Ref
Pistacia vera oleoresin
Antimicrobial properties
Strong anti-virulence
effect against
S. mutans and
reducing the
ability to form
biofilm
P. vera oleoresin can be
used in oral hygiene
products
Oleoresin, -pinen,
triterpenes
[53]
95% ethanol extract
of Piper betle with 3
different commercial
toothpastes
Antimicrobial Effect
against Escherichia
coli, Staphylococcus
aureus, S. mutans and
Streptococcus salivarius,
and Candida albicans
Toothpaste—
P. betle extract
combinations is
more effective
than those
exhibited by the
toothpastes alone
It can be used as effective
toothpaste ingredients
Phenolics
[54]
Deglycyrrhizinated
licorice extract
Antimicrobial activity
against Streptococcus
mutans biofilm
formation of
16 mg/mL of extract
is useful in the
development of oral
hygiene products
Phenolics
[47]
Herbal Products for Oral Hygiene 39
Tested herbal product
40 Natural Oral Care in Dental Therapy
2.6 Discussion
Oral diseases are one of the major health problems worldwide. Efficient oral hygiene is
important not only to prevent tooth decay and periodontal diseases but also to improve
various autoimmune conditions. Poor oral hygiene and oral diseases are associated
with chronic and systemic diseases. Therefore, the use of various herbal products has
been increasing in recent years in order to provide oral hygiene and prevention of oral
diseases [54].
Today, the daily oral hygiene routine is based on toothbrushing and/or mouth rinsing with mouthwashes. The traditional roles of dentifrices, toothpastes, powders, gel, or
mouthrinses are helping in the cleaning of teeth, oral cavity, and producing fresh breath.
Eid and Talic [55] compared the effectiveness of tooth brushing with toothpaste to the
effectiveness of tooth brushing with water. While a decrease of 67% in plaque formation was observed by brushing with toothpaste, 59% reduction in tooth brushing with
water was reported. Similarly, the effectiveness of rinsing before brushing on plaque
removal was examined by Binney et al. [56]. Rinsing then brushing removed more plaque
than any other combination of mouth rinse and dentifrice. According to the above results,
the function of different oral hygiene products in plaque formation and the removal of
plaque is still questionable. Chemical-based toothpaste or other products should be considered to provide oral hygiene.
Among dental hygiene products, dentifrices generally contain abrasive chemicals and/
or surfactants. There are many conflicting results about the plaque removal effect of these
combinations. In addition, research has shown that abrasion of dentifrice does not lead
to an increase in plaque removal. This result is also supported by the American Dental
Association Division of Science. Similarly, there is not enough evidence of the role of detergents (surfactants) in the plaque removal activity of dentifrices. Fluoride content is also
very important in oral hygiene products. The contribution of fluoride to caries prevention is
well known. However, fluoride did not show a standard and sustained effect on the control
of gingivitis. For this reason, it has been suggested that herbal products with antimicrobial,
antiplaque, and anti-inflammatory properties be added to eliminate some of the insufficient
properties of chemical-based dentifrices and mechanical plaque removal using toothbrush.
Since the most commonly used oral hygiene device is the toothbrush, it would be possible
to consider dentifrice as the best delivery method for herbal products that will provide
oral hygiene. However, herbal products that can provide both oral hygiene and therapeutic
properties in some oral diseases have not yet been successfully formulated to dentifrice with
a few exceptions. Problems of their formulation with herbal products are finding compatible constituents to keep the effectiveness of the product in addition to improving the taste,
smell, and the other flavor characteristics in the dentifrice formulation [57, 58].
Recently, it is well known that there is an enormous interest to use different traditional
herbal products for oral hygiene and dental health. As we summarized above, plants and
plant products have great potential in preventing oral diseases and maintaining dental
health. Therefore, the use of herbal products for oral hygiene and especially the production
of dentifrice containing herbal products should be promoted. Consumers, dentists, and
health professionals that are more informed about the use, safety, and effectiveness of the
various traditional medicines and over-the-counter products will increase the use of herbal
Herbal Products for Oral Hygiene 41
products effectively [59]. Our study provides short information on herbal products that
can be used for oral hygiene. The identification of the active ingredients of those plants and
their mechanisms of action may provide some useful leads for the development of more
effective and safer compounds or extracts in daily used oral hygiene products [60].
2.7 Conclusion
Nowadays, most of the population prefers oral hygiene preparations that contain plant
extracts due to safety problems and increased interest of individuals in natural-based products. When it comes to dental hygiene products, plants have been found to be safer and
effective in the growth of dental plaque and tooth decay. Therefore, increasing the use of
herbal products in mouth rinses and toothpastes will be useful in the control of dental
caries. However, the knowledge and understanding of herbal products and traditional uses
is still an ongoing process with respect to their effectiveness and safety. Further long-term
studies should be carried out to find suitable herbal formulations and provide their compliance with consumers and patients.
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42. Gazi, M.I., Lambourne, A., Chgla, A.H., The antiplaque effect of tooth paste containing
Salvadorapersica compared with chlorhexidine gluconate. Clin. Prev. Dent., 9, 3–8, 2008.
43. Rahmani, M.E. and Radvar, M., The anti-plaque activity of Salvadorapersica and padina essential oil solution in comparison to chlorhexidine in human gingival disease: A randomized
placebo-controlled clinical trial. Int. J. Pharmacol., 1, 311–315, 2005.
44. Singh, A., Daing, A., Dixit, J., The effect of herbal, essential oil and chlorhexidine mouthrinse
on de novo plaque formation. Int. J. Dent. Hyg., 11, 48–52, 2013.
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chlorhexidine and herbal oral rinse on dental plaque-induced gingivitis. J. Dent. Hyg., 80, 1–9,
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3
Go Green—Periodontal Care in the Natural Way
Siddhartha Varma* and Sameer Anil Zope
Department of Periodontology, School of Dental Sciences, Krishna Institute of Medical Sciences
Deemed to be University, Karad, India
Abstract
Ayurvedic medicine, a method of Hindu customary medicine indigenous to India, is gradually
engrossing much interest in developed countries such as the United States, Europe, and Japan.
Ayurveda basically encompasses the treatment of various ailments by the use of plant-based medicines. The naturally present phytochemicals in these medicines offer an efficient substitute to antibiotics and therefore signify a promising alternative approach in the prevention and remedial strategies
for oral infections. Periodontal diseases, one of the most prevalent oral diseases among adults worldwide, are considered to be the commonest cause of tooth loss. A range of antimicrobials and chemotherapeutic agents like triclosan, cetylpyridinium chloride, and chlorhexidine have been used in the
treatment of periodontal diseases. Dentists face an uphill task in treating periodontitis because of its
complexity in disease process and multifactorial etiology. Hence, herbal therapy has been sought to
achieve antimicrobial, anti-inflammatory, and other beneficial effects to tackle periodontal diseases.
This gradually led to an increasing popularity of complementary and alternative medicine over conventional allopathic approaches. Publicity of such ancient practices through an appropriate platform
would boost the confidence among the general population in maintaining good oral health.
Keywords: Ayurveda, gingivitis, herbal medicine, periodontitis
3.1 Introduction
Dental caries and periodontal diseases are known to be the two most significant oral health
problems worldwide, even though other conditions like oral cancers are also of major concern [1]. Approximately 90% of the people across the globe show prevalence of periodontal
diseases, which are considered to be one of the most common reasons for tooth loss amongs
the adult population [2]. The prevalence of periodontal disease in India has been investigated by national research scholars since 1940. Akhilesh H et al. in his systematic review
stated that some parts of Assam, Uttar Pradesh, and West Bengal reported more than 85%
prevalence of periodontal disease with 97.51% as the highest prevalence [3, 4].
Periodontal diseases are known to be one of the most universal infectious diseases of
mankind, which result in destruction of the supporting structures of the tooth. Periodontal
*Corresponding author: siddhartha_varma@yahoo.co.in
Durgesh Nandini Chauhan, Prabhu Raj Singh, Kamal Shah, and Nagendra Singh Chauhan (eds.)
Natural Oral Care in Dental Therapy, (45–60) © 2020 Scrivener Publishing LLC
45
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disease is multi-factorial in nature with periodontal microbes playing a main role in the
disease process. The presence of various types of microbes in the dental plaque eventually
leads toward the activation and recruitment of neutrophils. These neutrophils additionally
upregulate pro-inflammatory cytokines and release some reactive oxygen species (ROS)
and neutrophilic enzymes. The chronic exposure of the connective tissue to such insults
leads to the destruction of the periodontal ligament and the alveolar bone further resulting
in tooth loss [5].
Management of the periodontal disease includes both surgical and non surgical means.
The key to halt periodontal disease progression is by effective plaque control either mechanically by the use of toothbrush/floss or chemically by the use of mouthrinses [6]. Nevertheless,
lack of required skill and motivation among the majority of the population renders mechanical plaque control ineffective; consequently highlighting the adjunctive use of chemicals for
plaque control [7]. A range of antimicrobial and chemotherapeutic agents like cetylpyridinium chloride and chlorhexidine have proven to be effective in the treatment of periodontal
diseases. Dentists face an uphill task in treating periodontitis because of its complexity in
disease process and multifactorial etiology. The steady increase in incidence of periodontal
disease coupled with augmented antibiotic resistance by periodontal pathogens warrants a
comprehensive alternative approach which is safe, efficient, and cost effective.
An array of ayurvedic and herbal preparations are being used for oral hygiene procedures as well as for management of different oral diseases, which include, chewing sticks,
herbal brushes (Babool, miswalk, neem, and mango), aloe vera, turmeric, ginger, amla, and
garlic, etc. [8]. Properties like broad biological action, low cost, and superior safety margin
of the herbal products make them more preferable over conventional drugs. Active ingredients of plants and their materials used in herbal preparations or products are perceived
to have therapeutic benefits, which can achieve antimicrobial, antiseptic, antioxidant, antiinflammatory, and anti-collagenase effects [9]. A gaining popularity of complementary and
alternative medicine above traditional allopathic medicine is visible in the recent years,
which could be attributed to the products being natural and safe. Considering the importance of herbal medicines, the present section highlights the potential role of Ayurveda in
the treatment of various periodontal conditions.
3.2 Plaque Control
It is a well-established fact that the most basic aspect in preventing periodontal diseases is
an effective plaque control technique, which includes both mechanical means like brushing
and chemical means like mouthwashes. Ayurveda advocates various therapeutic measures
on a daily basis for managing oral health, which is comprised of Gandoosha (gargling) or
oil pulling, Jivha Lekhana (Tongue scrapping), and Dant Dhavani (Brushing).
3.3 Dant Dhavani (Brushing)
Avurveda suggests the use of chewing sticks daily in the morning and after every meal to
thwart oral diseases. The use of chewing sticks was widely practised since ancient times
in India, Middle East, and Africa. Datun is considered to be an excellent substitute for
Go Green—Periodontal Care in the Natural Way 47
toothbrush for dental plaque removal and prevention of oro-dental diseases. Its major
advantages are: it is economical, possesses numerous therapeutic properties, and its ease of
availability in most of the rural regions of India. It is a tool that necessitates no proficiency
or particular assets for its fabrication and marketing [10].
The fresh stems of neem (Azadirachta indica) and babool are famously used for chewing sticks. Liquorice (Glycyrrhiza glabra), milkweed plant (Calotropis procera), Arjuna
tree (Termmalia arjuna), black catechu (Acacia catechu Linn.), and fever nut (Caesalipinia
bouduc) are the other possible options for chewing sticks [11]. The twigs from a healthy tree
ought to be soft and with no leaves or knots. They must exhibit properties like “kashaya”
(astringent), “katu” (acrid), or “tikta” (bitter) in taste. As per ayurvedic practices, the herbal
brushes need to be approximately 9 inches in length and width equalling a little finger. The
technique of usage involves crushing one end of the stick followed by chewing and eating
it gradually [12]. Chewing the stems allegedly assist salivary secretions thereby probably
achieving better plaque control and a clean oral cavity. Neem extract contains the alkaloids
margosine, resins, gum, chloride, fluoride, silica, sulfur, tannins, oils, saponins, flavonoids,
sterols, and calcium thereby exhibiting significant and higher antiplaque efficacy compared to ayurvedic tooth powder and commercial toothpastes. Contemporary research has
revealed the medicinal and anti-cariogenic properties of chewing sticks as initially depicted
in Avurveda texts (Circa 200 BC) [13].
Mango leaves are also widely used for cleaning teeth in rural areas of southern India.
Mango leaves contain mangiferin, a compound that has a considerable antibacterial property against few strains of Streptococci, Staphylococci, Pneumococci, and Lactobacillus acidophilus. Mangifera indica consists of tannins resins and bitter gum. Extract of mango
chewing sticks at higher concentration showed more antimicrobial activity [14].
The use of miswak, a chewing stick obtained from the tree of Salvadora persica, is predominant in muslim countries and predates the inception of Islam. Al-Otaibi et al. concluded that using miswak was more effective than an ordinary toothbrush provided that
proper instructions are followed regarding its usage [15]. An in vivo study by Almas and
Zeid (2004) assessed the efficacy of miswak on S. mutans, and lactobacillus concluded the
instant antimicrobial effect of miswak [16].
3.4 Jivha Lekhana (Tongue Scrapping)
Tongue scraping is one of the most commonly ignored ayurvedic recommendation. Tongue
scraping helps in removing the tongue coating, which can lead to halitosis due to the presence
of microorganisms, and which can also have an impact on the systemic health. As described
in Ayurveda, inappropriate eating, digestive problems, or an evidence of discrepancy in the
gastrointestinal system results in the buildup of residual toxins in the body known as Ama.
An easy practice of tongue scraping helps in eradicating Ama from our physiology.
As per Charaka Samhita, the tongue scrapers must be prepared either from silver, tin,
gold, copper, and brass and should be blunt and curved to prevent any trauma to the tongue.
Scraping the tongue results in the stimulation of the reflex points and thereby improving
the taste sensation and increased secretion of digestive enzymes. Scientific data also confirms that regular use of a tongue scraper considerably eliminates anaerobic bacteria and
decreases halitosis [17].
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3.5 Gandusha (Gargling) or Oil Pulling
Oil pulling as described in Ayurveda involves swishing the oral cavity with oil to maintain
oral and systemic health. Gandusha as mentioned in Charaka Samhita claims to alleviate a range of systemic diseases like migrane, diabetes, and asthma, etc. Conventionally
since many years, halitosis and gingival bleeding were widely treated by oil pulling. Oil
prepared from sunflower and sesame is commonly used for oil pulling. Oil pulling therapy is extremely valuable in managing plaque-induced gingivitis when assessed in terms of
clinical findings and microbial counts [18].
3.6 Oxidative Stress in Periodontitis
Oxidative stress is a significant source of cell damage, which is linked with the initiation and
development of several chronic diseases including periodontitis [19]. The altered balance
between levels of prooxidants and antioxidants in favor of the former results in probable
tissue destruction. Molecules like superoxide anion, singlet oxygen, hydrogen peroxide,
hydroxyl radical, hypochlorous acid, and nitric oxide produced by oxidation–reduction
reactions of molecular oxygen by a variety of enzymes are termed as reactive oxygen species (ROS) [20]. In spite of the ability of all the body cells in generating ROS, polymorphonuclear neutrophils are primarily significant in relation to periodontitis. Evidence suggests
that osteoclasts primarily involved in bone resorption process are regulated by ROS [21].
The NADPH oxidase system is majorly involved in cases of aggressive periodontitis and
also plays a role in other periodontal pathologies [22].
All the cells of the human body are capable of storing antioxidants intrinsically, which can
combat the oxidative stress by scavenging the free radicals as and when produced. A variety
of antioxidant molecules consist of vitamins C, E, carotenoids, coenzyme Q, and enzymes
like glutathione reductase, superoxide dismutase, glutathione transferase, and peroxiredoxin.
Shirzaiy M et al. concluded that the patients who received periodontal therapy had a
significantly low level of total antioxidant capacity compared to healthy controls [23]. Such
observations have promoted the use of exogenous supplements in the form of herbal antioxidants for the management of periodontal diseases, which have been the focal point of
research in current times.
3.7 Green Tea
3.7.1 Components
The leaves of Camellia sinensis are processed with minimal oxidation to produce green tea.
The health-promoting benefits of green tea are mainly attributed to the concentrated levels of polyphenols, which exhibit antioxidant properties [24]. These polyphenols can be
primarily categorized into six types of catechins: catechin, gallocatechin, epicatechin, epigallocatechin, epicatechin gallate (ECg), and epigallocatechin gallate (EGCg). Among all
the catechins, EGCg has been extensively researched owing to its extremely potent antioxidant property. In addition to the catechins, green tea includes compounds like carotenoids,
Go Green—Periodontal Care in the Natural Way 49
tocopherols, ascorbic acid, minerals such as zinc, selenium, chromium, and certain phytochemicals [25].
3.7.2 Beneficial Effects of Various Tea Components
3.7.2.1 Antioxidative Effect
Green tea helps in inhibiting prooxidant enzymes and induces antioxidant enzymes, which
lead to scavenging of ROS, nitrogen species.
3.7.3 Role in Managing Periodontitis
Green tea catechins have proven to exhibit predominant effect on periodontopathogens.
Literature suggests that catechins inactivate P. gingivalis-induced collagenase. Catechins in
green tea successfully inhibit the growth of P. gingivalis, Prevotella intermedia, and Prevotella
nigrescens and also thwarts adhesion of P. gingivalis onto buccal epithelial cells of humans as
demonstrated in a few in vitro studies [26–28].
Bone resorption observed in periodontitis is due to interaction amid the osteoblasts
and osteoclasts. EGCg was found to curb LPS-mediated gene expression of RANKL,
cyclooxygenase-1 and the cytokine PGE2 in osteoblasts of mice. Catechins are remarkably effective in managing periodontal disease by suppressing the inflammatory
response-mediated bone resorption [29].
Green tea when used in the form of a dentifrice or a local drug delivery agent, improved
the oral health status of chronic periodontitis patients [30, 31]. Similarly, green tea when
used as a mouthwash for a period of 1 week had a similar antiplaque efficiency to that of
chlorhexidine gluconate, which is considered to be a gold standard [32]. These encouraging
results demonstrate that additional research is essential to explore the advantages of green
tea in the managing of periodontal diseases.
3.8 Turmeric (Curcumin longa, Haldi)
Turmeric is well known as sarvoshadhi in sanskrit, meaning medicine for all diseases.
Turmeric has been traditionally used in India for the past 2500 years and is known for
its actions like antibacterial, anti-inflammatory antiseptic, pain killer, and hepatoprotector.
Recent research in humans illustrates that the precancerous changes in oral submucous
fibrosis patients can be reversed with the use of turmeric extract and turmeric oil [33].
3.8.1 Applications of Turmeric in Dentistry
Turmeric encloses roughly 3–4% curcumin by dry weight [34].
1. Rinsing the oral cavity with turmeric water (5 g of turmeric powder, two cloves,
and two dried leaves of guava in 200 g of water) provides an instant pain relief.
2. A powder made from burnt turmeric pieces and Bishop’s weed seed when
used intra-orally provides strength to the teeth and gums.
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3. A paste prepared with 1 tsp of turmeric, ½ tsp of mustard oil, and ½ tsp of salt
used two times daily by rubbing on the gums provides relief from gingivitis
and periodontitis.
4. Roasted and ground turmeric when massaged on aching teeth reduces pain
and swelling.
5. Dental plaque detection system: It consists of curcumin and turmeric extract
and yellow pigment of beni-koji, along with a light-emanating apparatus,
which emits a 250- to 500-nm wavelength light [35].
3.9 Amala (Emblica officinalis, Amalaki, Phyllanthus emblica,
Indian Gooseberry, Dhatriphala)
Ayurveda considers amla, a well-known rasayana herb to maintain balance between all
the three doshas (vat, pit, and kuff). Amla extract can be taken orally per day (0.5 g) for
long-term benefits for the teeth and gums. Vitamin C present in amla acts as a cofactor in
the conversion of proline into hydroxyproline, which is one of the essential constituents of
connective tissue [36].
Chyawanprash and triphala are generally the two frequently utilized ayurvedic preparations containing amla. Its antioxidant and astringent properties are demonstrated to be
valuable in the management of toothache, apthous stomatitis, mouth ulcers, and gingival
inflammation [37].
3.10 Anar/Dalima (Punica granatum)
The pomegranate fruit including its peel, seeds, oil, powdered extracts, and juice have medicinal properties and exhibit no side effects. Pomegranate flavonoids have anti-inflammatory and
antibacterial properties, and pomegranate polyphenols have antioxidant and antiviral properties [38]. The antibacterial action of Punica granatum is attributed to the presence of ellagitannin and punicalagin [39]. Studies have showed that pomegranate extract, as a mouthrinse,
showed the capacity to remove dental plaque, increased antioxidant activity, decreased activity
of aspartate aminotransferase and proteins [39, 40], and inhibited major periodontal pathogens
like Aggregatibacter actionomycetemcomitans, Porphyromonas gingivalis, and Prevotella intermedia [41–43]. Pomegranate extract gel when used as an adjunctive treatment option along
with scaling and root planing significantly reduces the inflammatory status of gingiva [44].
3.11 Launga/Clove (Syzygium aromaticum)
Clove oil can be used to treat oral ulcers and sore gums due to its gentle anesthetic property.
It also battles oral infections and inflammation because of its strong antibacterial activity
and even decreases halitosis [45]. Eugenol is considered as an active component (including
β-caryophyllene) and also contains a variety of flavonoids; hence, it is extensively used as
temporary fillings, in conjunction with root canal therapy, intra-oral abscesses, and painful
gums [46, 47].
Go Green—Periodontal Care in the Natural Way 51
3.12 Gotu Kola (Centella asiatica)
Its property in promoting growth of connective tissue aids in wound healing and thus is
effective in the treatment of oral ulcers. According to Sastravaha et al. treatment of chronic
periodontitis with Centella asiatica and P. granatum in the form of biodegradable chips
showed a significant improvement in decreasing plaque, periodontal pocket depth, and loss
of attachment at the end of 3 months in comparison to a placebo [48]. Gotu kola can also
be used in enhancing recuperation after laser surgical procedures used for treating severe
periodontal disease. The daily suggested dosage is 30 mg of triterpenoids two times, and it
may vary depending on the content of triterpenic acid [49].
3.13 Amra/Mango (Magnifera indica)
Mango leaves exhibit anti-bacterial properties due to the presence of ascorbic and phenolic acids. It was found to be effective against anaerobic microorganisms such as Prevotella
intermedia and Porphyromonas gingivalis and therefore can be used as an adjunct in oral
hygiene maintenance [50].
3.14 Neem (Azadirachta indica)
The anti-bacterial, anti-inflammatory, analgesic, antioxidant, antifungal, antiviral, and
immunostimulant properties of neem have been well documented in literature [51]. It
compasses mechanical and chemotherapeutic antiplaque agents. Anirban Chatterjee et al.
evaluated the antiplaque efficacy of neem as oral rinse on gingivitis when used an adjunctive therapy. They concluded that the presence of gallotannins in neem could effectively
decrease the bacterial count in dental plaque [52]. Antibacterial plant extracts have an
advantage over antibiotics as they produce no allergy nor exhibit any resistance. An herbal
mouthrinse formulation prepared with active fractions from Azadirachta indica, Citrullus
colocynthis, and Cucumis sativus extract with a carrier or additive was effective in preventing gingivitis and periodontal diseases [53].
3.15 Tulsi (Ocimum sanctum)
Tulsi is found on a large scale in India, Malaysia, West Africa, Australia, and some of the
Arab countries. Majority of the therapeutic actions of tulsi are present in its leaves, while
other parts of the plant like flowers, stem, root seeds, etc., are also known to have some
medicinal potential. The extract of tulsi leaves includes 0.7% volatile oil, which comprises
71% eugenol and 20% methyl eugenol. The anti-inflammatory activity of tulsi against prostaglandin E2 (PGE2), leukotriene, and arachidonic acid-induced edema has been found
due to the presence of fixed oil and linolenic acid [54]. Tulsi leaves when chewed raw help
in maintaining oral hygiene. Carracrol, Tetpene, and Sesquiterpene b-caryophyllene are
the antibacterial agents present in this plant. The powder of sun-dried tulsi leaves or a mixture with mustard oil can be used as a dentrifice. Tulsi was also proven to be effective in
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counteracting halitosis. The anti-inflammatory property of tulsi makes it an appropriate
medication for treating gingivitis and periodontitis [55].
3.16 Nilgiri (Eucalyptus globulus)
Eucalyptus extract is known to have anti cariogenic and anti-plaque property. Chewing
gum containing Nilgiri demonstrated a considerable positive consequence on dental plaque
accumulation, gingival index, bleeding on probing, and periodontal probing depth [56].
Essential oils have been gathering recognition since the past decade especially for the
prevention and management of several infections. The antibacterial action of Eucalyptus oil
in the management of colds, influenza, other respiratory infections, rhinitis, and sinusitis
has been well recognized for ages [57]. Ragul et al. stated that mouthwash containing eucalyptus oil was similarly effective as chlorhexidine mouthwash (0.12%) in plaque control,
and therefore, it could be considered as a good and economical oral hygiene aid [58].
3.17 Tila/Sesame (Sesamum indicum)
It is rich in vitamin E and flavonoid phenolic antioxidants. Ashokan et al. conducted a study
on oil pulling therapy using sesame oil in managing gingivitis. They concluded that sesame
oil significantly decreased the number of aerobic microorganisms, plaque index, and modified gingival scores in adolescents suffering from plaque-induced gingivitis [59].
3.18 Triphala
The dry fruits of Amalaki (Emblica officinalis), Haritaki (Terminalia chebula), and Bahera
(Terminalia belerica) together constitute Triphala. At a concentration of 1500 µg/ml, it
potently inhibits PMN-type collagenase, especially MMP-9. It has shown good antimicrobial, antioxidant and anti-collagenase activities and is also used for strengthening the
gums [60]. The antioxidants in Triphala decrease the oxidative burden and prevent free
radical-induced cell damage. Among the three medicinal plants in triphala, Bahera is the
strongest antioxidant followed by Amalaki and Haritaki. A randomized clinical study has
demonstrated that Triphala mouthwash is as efficient as chlorhexidine (0.2%) in antiplaque
and anti-inflammatory actions [61].
3.19 Tea Tree Oil (Melaleuca Oil)
Tea tree oil (TTO) with antibiotic properties helps in curing the infection of periodontal
disease. It has been used to treat severe chronic gingivitis, bleeding gums, and halitosis,
as they deeply penetrate into the skin. Elgendy et al. in their randomized clinical trial,
used tea tree oil gel for local application in chronic periodontitis patients and proved
it to be beneficial in augmenting the results of SRP. Furthermore, they emphasized on
Go Green—Periodontal Care in the Natural Way 53
monitoring pentraxin (PTX3) levels in GCF as a marker of tissue healing following periodontal therapy [62].
3.20 Rumi Mastagi/Mastic Gum (Pistacia lentiscus)
It is recognized for its strong anti-inflammatory, antioxidant, and bactericidal effects.
Koychev et al. studied the possible use of mastic gum for improvement of periodontal health.
They concluded that mastic extract significantly inhibited potential periodontal pathogens,
namely, P. gingivalis, S. oralis, A. actinomycetemcomitans, F. nucleatum, and P. intermedia
and also exhibited a valuable effect on cell viability on comparison with H2О2. Therefore, it
could be considered a viable antibacterial agent in the management of periodontal disease
[63].
3.21 Wheat Grass
Wheatgrass is the young grass shoots of the Triticum aestivum plant and exhibits antioxidant, antibacterial, and anti-inflammatory properties. Wheatgrass juice or wheatgrass supplement is known to prevent gingivitis and periodontal disease thereby eliminating bacteria
in the oral cavity [64].
3.22 Goldenseal (Hydrastis canadensis)
Bererine in goldenseal is an effective antibacterial, antiviral, and antifungal agent. Goldenseal
acts as an astringent and helps in treating gingivitis. Using a rinse made from one teaspoon
dissolved in water or applying the goldenseal powder directly to the gums is believed to be
effective for many gum problems, including canker sores. Bhandari et al. in their in vitro
study, established that goldenseals extract exhibits promising antibacterial activity against
selected periodontal pathogens [65].
3.23 Licorice Root
The American Dental Association considers that the antibacterial and antiviral properties
of licorice restrains plaque buildup and therefore helps in the management of periodontal disease, oral ulcers, and canker sores. Licorice root powder, paste, and decoction for
mouthwash are one of the best for managing inflammation in periodontal disease [66].
Licorice root can cause severe side effects and some unfavorable drug interactions and
therefore should be used with a degree of caution and in consultation with a health care
specialist. Alaa Omran Ali et al. in their recent study, concluded that a mouthwash containing liquorice extract reduced the amount of plaque and gingival inflammation, and it can be
used for a prolonged duration with no side effects as an adjunct to scaling and root planing
in the management of periodontal disease [67].
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3.24 Myrrh (Commiphora glileadenis)
Myrrh has been used since prehistoric times for a variety of medicinal remedies like
inflamed gums, canker sores, throat and nasal infections, and breathing issues. Hence, one
of the excellent methods to lessen bacteria and preserve oral health is using a mixture of
myrrh oil with warm water as a mouthwash. Hossam A Eid et al. stated that the myrrh
plant extract showed potential antibacterial property. It also exhibited significant results in
controlling the biofilm of S. mutans, which supposedly plays a major role in the etiopathogenesis of dental caries and periodontal diseases [68].
3.25 Psidium guajava
Guava is principally rich in Vitamin C (ascorbic acid) and therefore exhibits an excellent
antioxidant property. Its antioxidant action is augmented by the presence of carotenoids,
quercetin, and polyphenols [69]. The extract of guava leaves and essential oil from its stem
act as scavengers and aid in the inhibition of hydroxyl radicals [70, 71]. A decoction prepared from the root bark or leaves can be recommended as a mouthrinse, which can effectively mange bleeding gums [72].
3.26 Ginkbo Biloba
G. biloba (EGb) leaf extract is used extensively as an herbal nutritional supplement in the
US. It is composed of terpenoids, ginkgo flavone glycosides, and ginkgolic acid (less than
5 ppm). It acts as a scavenger of the free radicals, lowers oxidative stress, and exhibits antiinflammatory effect [73]. Sezer U et al. stated in ligature-induced periodontitis rat model,
systemic administration of EGb (28–56 mg/kg/day) reduced osteoclastic counts, decreased
inflammation, and induced osteoblastic activity [74].
3.27 Honey
Honey was recommended since primeval times in various cultures to manage infections
and many medical ailments. The antibacterial factors of honey are mainly due to the hyper
osmolarity effect (>80% sugar content), bee defensin-1, methylglyoxal, hydrogen peroxide,
acidic pH, a range of phenolic and proteinaceous compounds, and flavonoids. However,
the primary antimicrobial activity of honey is due to the presence of hydrogen peroxide
[75]. It helps in the maintenance of healthy gums because of the rich presence of minerals, vitamins, and other vital nutrients. Duailibe et al. concluded that propolis mouthwash
exhibited potent antimicrobial activity against Streptococcus mutans and can be prescribed
as an alternative to conventional mouthwashes in the management of dental caries and
periodontal diseases [76].
Based on clinical and microbiological parameters, Amita Coutinho et al. reported that
sub-gingival irrigation with propolis extract (20%) as an adjunct to periodontal treatment
Go Green—Periodontal Care in the Natural Way 55
was more effective than scaling and root planing alone [77]. Similarly Atwa AD et al. suggested that honey (topical application/chewing) is an effective substitute to conventional
remedies in preventing gingivitis and dental caries following orthodontic treatment [78].
3.28 Other Herbs Which Can Be Potentially Used for Treating
Periodontitis
Cymbopogon citratus (lemon grass), Allium sativum (garlic), Eucalyptus globulus (eucalyptus), Murraya koenigii (curry leaves), Shiitake mushrooms lentinan, etc., can also be used.
Even though several studies have revealed the effectiveness of herbal medicines as a substitute to established therapeutic procedures, the clinical application of such agents is yet to be
supported by ample evidence.
3.29 Conclusion
As per Ayurvedic classics, a variety of herbs are recommended for plaque control and management of periodontal diseases. According to estimates of the World health Organization
(WHO), around 75% people worldwide use herbs for their fundamental health care
needs. WHO has recommended for the incorporation of the traditional systems of medicine like Ayurveda into the primary health care system, among communities who accept
it (Table 3.1). All the ayurvedic medicines and local remedies discussed above are easily
accessible in the rural areas where socioeconomic conditions of the people are not good.
Ayurveda must be reinterpreted in the light of new emerging knowledge, and it must be
Table 3.1 Classification of Herbal Medicines [79].
Category I:
Indigenous herbal medicines
Includes medications well recognized by the local
inhabitants/society since historic times in perspective to
their dosage, content, and treatment options.
Category 2:
Herbal medicines in systems
Medicines appropriately recognized by individual
countries on the basis of well-established concepts and
theories.
E.g.: Ayurveda, Siddha, and Unani
Category 3:
Modified herbal medicines
Herbal medicines, which are customized with respect to
their composition, administration mode, dosage, and
shape and fulfilling the safety and efficacy requirements
of respective national regulatory bodies along with
those depicted in categories 1 and 2.
Category 4:
Imported products with an herbal
medicine base
Herbal medicines either in the form of final products
or raw materials with essential efficacy and safety
information at an authorized national center in the
country of import.
56
Natural Oral Care in Dental Therapy
incorporated in modern medicine along with other forms of traditional medicine. The
key is to figure out what works best for the treatment of the patient. Additional studies
on plaque-inhibiting effect of various herbal formulations are obligatory to establish their
duration of action. Herbal products may vary in their effectiveness; therefore, it is necessary
to select herbal preparations carefully. Herbs and their extracts can be used as adjuvant in
periodontal disease treatment.
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4
Role of Herbal and Natural Products
in the Management of Potentially
Malignant Oral Disorders
P. Kalyana Chakravarthy1*, Komal Smriti2 and Sravan Kumar Yeturu3
1
Department of Public Health Dentistry, Manipal College of Dental Sciences, Manipal,
Manipal Academy of Higher Education, Manipal, Karnataka, India
2
Department of Oral Medicine and Radiology, Manipal College of Dental Sciences, Manipal,
Manipal Academy of Higher Education, Manipal, Karnataka, India
3
Public Health Dentistry, Amrita School of Dentistry, Amrita Vishwa Vidyapeetham, Cochin, Kerala, India
Abstract
Potentially malignant oral disorders are visibly abnormal areas of the oral mucosa, which are white
keratotic, raised roughened areas, which have the probability of malignant transformation. These
may be a source of significant anxiety for the patient and the clinician. Though not all premalignant
lesions transform into oral carcinomas, certain high-risk lesions have been identified such as leukoplakia, lichen planus, and oral submucous fibrosis. Their management remains controversially polarized between surgical excision to prevent malignant change and conservative medical or surveillance
techniques. Drugs obtained from plant extracts, like lycopene, have been recently used in the treatment of leukoplakia and oral submucous fibrosis (OSMF). Beta-carotene and the retinoids are the
most commonly used antioxidant supplements for chemoprevention. Beta-carotene is a carotenoid
found primarily in dark green, orange, or yellow vegetables. Turmeric and its active ingredient “curcumin” are being studied upon as chemopreventive agents in the management of OSMF. Tulsi and
turmeric offers a safe and efficacious combination of natural products for symptomatic treatment
of both burning sensation and mouth opening in patients of OSMF. Ayurvedic preparations like
Erandabhrishta Haritak and Pippalyadi Choorna have been used in OSMF. This chapter focuses on
various modalities currently available and discusses the efficacy and safety of such herbal products
and natural extracts in the management of potentially malignant oral disorders.
Keywords: Potential, malignant, oral, dental, fibrosis, submucous, lichen planus, leukoplakia
4.1 Introduction
Potentially malignant oral disorders are visibly abnormal areas of oral mucosa, which
are white keratotic, raised roughened areas, which have a probability of malignant
*Corresponding author: drkalyan81@gmail.com; kalyan.cp@manipal.edu
Durgesh Nandini Chauhan, Prabhu Raj Singh, Kamal Shah, and Nagendra Singh Chauhan (eds.)
Natural Oral Care in Dental Therapy, (61–80) © 2020 Scrivener Publishing LLC
61
62 Natural Oral Care in Dental Therapy
Natural or herbal products
Potentially malignant disorders
OSMF
OLP
OL
Aloe vera
Green tea extracts
Aloe vera
Beta–carotene
Beta carotene
Lycopene
Lycopene
Lycopene
Turmeric extracts
Colchicine
Turmeric extracts
Raspberry leaf extract
Tea pigments
Alpha-tocopherol
Purslane
Spirulina
Chinese Herbal Medicines
Chinese herbs
Bowman-Birk inhibitor
concentrate
Turmeric extracts
Nigella sativa
Ocimum (Tulsi)
Polyherbal formulations
Ayurwedic formulations
Figure 4.1 List of natural products for pharmacological management of potentially malignant disorders of the
oral cavity.
transformation. These may be a source of significant anxiety for the patient and the clinician. Many such lesions like oral submucous fibrosis, leukoplakia, and lichen planus have
high risk of transformation to malignancies. Their management has a wide range of options,
which include surgical excision, intra-lesional, topical, or systemic medication.
Drugs obtained from plant extracts (beta-carotene and the retinoids) have been recently
used in the treatment of leukoplakia and oral submucous fibrosis (OSMF). Tulsi, turmeric, and extracts are used in the management of OSMF. Pure ayurvedic preparations like
Erandabhrishta Haritak and Pippalyadi Choorna have also been tried in OSMF (Figures 4.1
and 4.2). This chapter focuses on various modalities currently available and discusses the efficacy of herbal and natural extracts in the management of potentially malignant oral disorders.
4.2 Oral Submucous Fibrosis (OSMF)
4.2.1 Background
OSMF is defined as an “insidious chronic condition of multifactorial etiology affecting the
oral mucosa characterized by dense collagen tissue deposition within submucosa, occasionally extending to the pharynx and esophagus”. It has distinct clinical characteristics
viz., “blanching and stiffness of oral mucosa, trismus, BS, loss of mobility of tongue and
loss of gustatory sensation” [1]. The main etiological agents for OSMF are areca nut with
or without tobacco and tobacco chewing in all forms. There is no ideal treatment protocol for the management of OSMF. Cessation of the habit is a prerequisite for planning
the treatment. Khanna and Andrade suggested that early stages of OSMF can be treated
effectively with various medical intervention, and advanced stages often require surgical
Role of Herbal and Natural Products 63
TOBACCO
AT
WORK
LEUKOPLAKIA
ORAL
SUB MUCOUS
FIBROSIS
ORAL
CANCER
LUNG
BRAIN
DEXTER
CLUB
I AM PLANNING
TO TAKE
ORAL ROUTE
HEART
HOW??
MAN .. I CAN .......
KILL A HUMAN RIGHT NOW ...
BUT THERE ARE
“THE GUARDIANS”...
FOODS TO FIGHT
CANCER
PLANT EXTRACTS TO
IMPROVE IMMUNE
SYSTEM
TOMATOS
BERRY
CARROT
TURMERIC
TULSI
PEPPER
SPIRULINA
ALOE VERA
TEA PIGMENTS
Figure 4.2 Illustration showing the role of risk factors and natural products in potentially malignant disorders
of the oral cavity.
management. Medical interventions are administered as a variety of modalities: orally for
systemic absorption, intra-lesional, or topical as single or combination of agents [2]. Many
herbal formulations have been tried for the treatment of OSMF with variable efficacy.
4.2.2 Beta-Carotene
Beta-carotene was shown to have properties that help in cancer prevention like anti-oxidant,
immunomodulation, inhibition of mutagenesis, and growth of cancer cells.
64 Natural Oral Care in Dental Therapy
Aggarwal et al. [3] analyzed serum beta carotene in OSMF patients and compared with
age- and gender-matched controls. A significantly lower mean serum beta carotene was
seen in OSMF than the control group. Similarly, lower levels of serum beta carotene were
evident in grade III compared with grades I and II OSMF patients.
Jirge et al. [4] evaluated the clinical and serum immunoglobulins (IgG, IgA, and IgM)
effects of levamisole and Antoxid (beta carotene, zinc sulfate monohydrate, selenium dioxide, manganese, copper). Participants were divided into three groups, viz., levamisole only
(50 mg thrice daily for 3 alternate weeks), Antoxid (twice daily for 6 weeks), combination of
levamisole and Antoxid. Significant improvement in the mouth opening (MO) and reduction in burning sensation (BS) was seen in all the groups. Serum IgG, IgA, and IgM were
significantly reduced in levamisole and combination groups. The Antoxid group showed
significant reduction in serum IgA and IgM.
Thriveni et al. [5] evaluated the effect of natural beta-carotene and revox in the oral
management of OSMF patients. A total of 50 patients were divided into group A [hyaluronidase + hydrocortisone (bilaterally alternative week) and natural carotene (12 weeks)] and
Group B [hyaluronidase + hydrocortisone (bilaterally in alternative week) and revox capsule (12 weeks)]. Both the groups were advised ice cream stick mouth exercises. Significant
improvement was seen in mouth opening; reduced BS was seen in all the patients with early
response in group A than in B.
4.2.3 Lycopene
Lycopene is a potent antioxidant with very effective free radical scavenging property.
Alternate anti-carcinogenic effects is through the regulation of communication at gap junction [6], induction of apoptosis, and modulation of carcinogen-metabolizing enzyme [7].
Kumar et al. [8] evaluated the efficacy of oral lycopene in 58 OSMF patients who were
randomized into three groups. Patients of groups A, B, and C received lycopene, lycopene +
intra-lesional steroids, and placebo, respectively. Significant improvement in mouth opening and BS was seen only in groups A and B. BS was relieved within 2 weeks use of oral
lycopene in groups A and B.
Karemore et al. [9] evaluated the role of lycopene in OSMF patients. A total of 92 patients
were divided into two groups (lycopene and placebo). Significant improvement in mouth
opening and reduced BS was seen with lycopene.
Patil et al. [10] evaluated lycopene and AV in 120 OSMF patients. They were divided
equally into the lycopene group (8 mg in two divided doses) and AV group (5 mg topical gel
thrice daily for 3 months). Significant improvements in MO and tongue protrusion (TP) were
seen in the lycopene group. BS, pain, swallowing, and speech improved in both the groups.
Selvam et al. [11] aimed to evaluate oral lycopene therapy + conventional intra-lesional
steroid injections in the management of OSMF. Forty-five OSMF patients (grades III and
IV) were randomly divided into three groups viz., oral lycopene (16 mg/day), oral antioxidant capsules, and control group. All the three groups received twice a week intra-lesional
steroids + hyaluronidase. There was complete relief of BS and significant increase in MO
within 3 weeks among all the patients. Significant improvement in MO was seen with oral
lycopene and oral antioxidant capsules compared with the control group. Supplementation
of oral lycopene or oral antioxidants to the control intervention (intra-lesional steroids +
hyaluronidase) was shown to be beneficial.
Role of Herbal and Natural Products 65
Piyush et al. [12] compared lycopene, curcumin, and placebo in a randomized controlled
parallel trial in 90 OSMF patients. They were randomly divided into three groups viz., curcumin (300 mg twice daily), lycopene (8 mg twice daily), and placebo groups, respectively.
The mean difference in the MO, BS, and cheek flexibility (CF) scores was significantly
higher in curcumin and lycopene groups than placebo. However, there was no significant
difference in the mean difference in the TP among the groups.
Saran et al. [13] compared the efficacy of lycopene and curcumin (Curcuma longa and
Piper nigrum) given orally in 60 OSMF patients divided into two groups. After 3 months,
there was complete cessation of BS in both the groups. No significant difference was seen
between the groups with respect to the increase in the MO. Lycopene showed significantly
higher improvement than curcumin.
4.2.4 Aloe Vera
Aloe vera (AV) is an “emollient resin with many multitude of benefits like analgesic, antiinflammatory, immune modulatory, antioxidant, anti-neoplastic, and wound-healing
properties” [14]. Considering the above properties, it was evaluated as a natural herbal
alternative for the management of OSF.
Alam et al. [15] conducted a randomized double blind placebo controlled trial to evaluate AV gel as an adjuvant in the treatment of OSMF. Sixty subjects were divided into medicinal (hyaluronidase + dexamethasone injections) and surgical groups. Each category was
sub-divided into with and without AV supplementation. AV supplementation had a significant improvement in most symptoms than without AV in both medical and surgical groups.
Anuradha et al. [16] evaluated AV in the treatment of OSMF in 74 patients randomly
divided into two groups (systemic juice + topical AV for 3 months versus intra-lesional
hydrocortisone + hyaluronidase injections for 6 weeks with antioxidants for 3 months).
Both the groups showed significant reduction in BS and increased MO, CF, and TP at the
end of 3 months.
Patil et al. [17] compared spirulina and AV in the management of OSMF. All the subjects
(n = 42) were randomly divided into spirulina (500 mg in two divided doses for 3 months)
and AV groups (5 mg topical gel thrice daily for 3 months). The spirulina group showed
significant improvement in MO and ulcers/erosions/vesicles. There was no difference in the
improvement in BS and pain associated with the lesion between the groups.
Patil et al. [18] compared the oxitard (two capsules twice daily) and AV (5 mg topical
gel thrice daily for 3 months) in 120 OSMF subjects. Significant improvements in MO, TP,
pain associated with the lesion, difficulty in swallowing, and speech were seen in the oxitard
group. No difference in the BS was seen between the groups.
Singh et al. [19] compared AV versus antioxidant supplementation with physiotherapy
in the management of OSMF. A total of 40 subjects were divided into AV with physiotherapy and antioxidant with physiotherapy. Significant improvement in MO, TP, CF, and
reduction in burning scores was seen with AV gel with physiotherapy in comparison with
antioxidants with physiotherapy.
Sudarshan et al. [20] compared the AV and antioxidants in the treatment for OSMF.
Twenty OSMF subjects were divided into two groups (5 mg of topical AV gel, thrice daily for
3 months versus antioxidant capsules twice daily for 3 months). There was significant reduction in the BS and improvements in MO and CF in the AV group than in the antioxidants.
66 Natural Oral Care in Dental Therapy
Al-Maweri et al. [14] conducted a systematic review on the effectiveness of AV in the
treatment of OSMF. Six randomized controlled trials were identified out of which five studies used only topical gel, while one study used both topical and systemic AV routes. Metaanalysis showed significant differences in favor of AV in reducing pain/BS at the end of the
first and second months, but no such effect was seen at the end of the third month. No significant difference was seen with respect to objective clinical outcomes between the groups.
AV reduced pain/BS. However, marked heterogeneity was seen among the included studies.
4.2.5 Colchicine
Colchicine is well known for its antifibrotic property. It inhibits collagen synthesis and disrupts the microtubule formation and depolymerizes microtubules preventing the extrusion
of collagen fibers from the fibroblasts.
Krishnamoorthy and Khan [21] studied the effects of colchicine in 50 OSMF who were
divided randomly into two groups viz., colchicine group (0.5 mg twice daily and intralesional hyaluronidase once a week) and Hyaluronidase + Hydrocortisone group (once a
week intra-lesional, alternatively). Inter-group comparisons with respect to MO and histological parameters indicated that colchicine, with hyaluronidase responded well than hyaluronidase + hydrocortisone. In both the groups, BS was relieved in all the patients.
Daga et al. [22] compared the effectiveness of oral colchicine with intra-lesional injection of hyaluronidase or injection triamcinolone acetonide in 30 grade II OSMF patients
randomly divided into two groups (colchicine 0.5 mg twice daily + weekly intra-lesional
hyaluronidase versus colchicine 0.5 mg twice daily + weekly intra-lesional triamcinolone
for 12 weeks). Improvement in MO and reduction in BS was significant in oral colchicine
with hyaluronidase. However, improvement in blanching of mucosa was seen in both the
groups.
4.2.6 Tea Pigments
Tea pigments have polyphenols that are derived from tea leaves. Li et al. [23] conducted
a study in 39 OSMF patients to evaluate tea pigments. The control group was administered with vitamins A, D, E, and B complex, and the experimental group was administered
tea pigments along with the vitamins in the control group. Tea pigments have antioxidant
property and improve microcirculation in these patients. The results of the experimental
group were significantly better than that of the control group. The results indicated that tea
pigment may possibly become a better therapy for the OSF patients with abnormal hematological parameters.
4.2.7 Spirulina
Spirulina is a microalgae, which is rich in proteins, carotenoids and micronutrients that are
known to have antioxidant properties [17]. Shetty et al. [24] evaluated spirulina as an adjunct
in the management of OSMF among 40 patients divided into spirulina group (500 mg twice
daily + biweekly intra-lesional Betamethasone) and placebo group (placebo capsules twice
daily + biweekly intra-lesional Betamethasone). Significant improvement in MO and BS was
Role of Herbal and Natural Products 67
seen in both the groups. Inter-group comparison showed that MO and BS were significantly
in favor of the spirulina group at the end of 3 months.
Patil et al. [17] compared the spirulina and AV in the management of OSMF. Subjects
were divided into the spirulina group (500 mg spirulina in two divided doses for 3 months)
and AV group (5 mg AV topical gel, thrice daily for 3 months). The spirulina group showed
significant improvement in MO and ulcers/erosions/vesicles, while no improvement was
seen with BS and pain associated with the lesion between the two groups.
Mulk et al. [25] studied the efficacy of spirulina and pentoxyfilline in the treatment of
OSMF in 40 subjects divided into Pentoxyfilline and Spirulina groups. Both the groups
showed significant results in the improvement of MO and TP and reduction in BS. Intergroup comparisons showed no significant difference in the improvement of MO and TP
between the two groups. A significant higher reduction in BS was seen in spirulina.
Zwiri et al. [26] compared pentoxifylline and spirulina in the management of OSMF in
112 subjects. Subjects were divided into pentoxifylline (400 mg pentoxifylline twice daily)
and spirulina (500 mg spirulina in two divided doses) groups. The patients in both the
groups showed improvement in all the parameters measured. Significant improvement
in MO, reduction in pain associated with the lesion, and BS were seen in the pentoxifylline group, while the spirulina group showed significant improvement in ulcers/erosions/
vesicles.
4.2.8 Chinese Herbal Medicines
Salvianolic acid B [27] is the most bioactive component of Radix salvia miltiorrhizae, which
is a popular traditional Chinese medicine. Previous in vitro study have shown the antifibrotic activity of salvianolic acids A and B [28]. Panax notoginseng saponin is another
Chinese herb, which also showed excellent anti-fibrotic activity in vitro [29].
Wu et al. [30] evaluated the therapeutic effect of Salvia miltiorrhiza and prednisolone in
120 medium and advanced stage OSMF patients. Subjects were divided into Salvia miltiorrhiza + prednisolone and prednisolone groups. Significant decrease in the lesion area and
increase in MO were seen in both medium and advanced stages in the Salvia miltiorrhiza +
prednisolone group. However, such improvements were seen only in the medium stages of
OSMF when treated with prednisolone only. No difference was seen in the advanced stages
of OSMF. Combined Salvia miltiorrhiza + prednisolone therapy showed better efficacy in
advanced stages of OSMF than prednisolone only, while medium stages of OSMF did not
have any difference between the groups.
Jiang et al. [31] conducted a randomized clinical trial for the effectiveness of intra-lesional
triamcinolone acetonide, intra-lesional salvianolic acid B, and combined intra-lesional triamcinolone acetonide + salvianolic acid B in the treatment of OSMF for 20 weeks in 42 subjects. Combined therapy (triamcinolone acetonide + salvianolic acid B) was more effective
than intra-lesional triamcinolone acetonide or salvianolic acid B alone in the improvement
of MO and reduction of BS.
Jiang et al. [32] evaluated the efficacy of allicin in a randomized clinical trial among
48 stage II OSMF subjects. Subjects were randomized into intra-lesional Triamcinolone
acetonide or allicin groups. Allicin group significantly improved MO, BS, and oral
health-related quality of life than Triamcinolone acetonide at the end of 40 weeks.
68 Natural Oral Care in Dental Therapy
4.2.9 Turmeric and Derivatives, Nigella sativa, Ocimum
The active ingredient in turmeric is curcumin, which is a chemopreventive agent. It can act
both as a scavenger or catalyzes the formation of hydroxyl radicals.
Hastak et al. [33] studied the effect of turmeric, turmeric oil, and turmeric oleoresin
in OSMF patients for 3 months. All the three derivatives decreased the number of micronucleated cells both in exfoliated cells of oral mucosal and circulating lymphocytes with
Turmeric oleoresin as the more effective.
Das et al. [34] evaluated the efficacy of curcumin capsules and turmeric oil in 48 OSMF
patients. Subjects were divided into curcumin, turmeric oil, and control (multinal tablets)
groups. A significant reduction in BS, pain, and improved MO was seen with curcumin and
turmeric oil groups at the end of 3 months. The curcumin group showed faster improvements, whereas the turmeric group showed long-term effects on the symptoms.
Hazarey et al. [35] evaluated curcumin in the treatment of OSMF. Thirty OSMF
patients were divided into curcumin lozenges and control (clobetasol propionate 0.05%)
groups. Curcumin group showed improved MO and decreased BS compared to the control group. The effect was sustained in the curcumin group, while relapse was seen in the
control group at the end of 6 months.
Pipalia et al. [36] compared turmeric with black pepper and Nigella sativa in 40 OSMF
patients. Subjects were randomized into turmeric + black pepper and Nigella sativa groups
with a follow-up of 3 months. Both the groups showed improvement in MO, reduction in
BS, and improvement in serum superoxide dismutase levels.
Piyush et al. [12] compared lycopene and curcumin with placebo in a randomized controlled
parallel clinical trial on 90 OSMF patients. The mean difference in the MO, BS, and CF scores
was significantly higher in the curcumin and lycopene groups than the placebo. However, there
was no significant difference in the mean difference in the TP among the groups.
Saran et al. [13] compared the efficacy of lycopene and curcumin (Curcuma longa and
Piper nigrum) given orally in 60 OSMF patients divided into two groups. After 3 months,
there was complete cessation of BS in both the groups. No significant difference was seen
between the groups with respect to the increase in the MO. Lycopene showed significantly
higher improvement than curcumin.
Srivastava et al. [37] evaluated the clinical efficacy of tulsi and turmeric mixed for the
treatment of OSMF in 41 patients. Significant improvement was seen in BS and MO when
compared with baseline scores.
Yadav et al. [38] evaluated the efficacy of curcumin in OSMF patients in a randomized open label, interventional trial in 40 OSMF patients randomized into intra-lesional
Dexamethasone + Hyaluronidase group and Curcumin tablets group. BS improved in both
the groups with complete resolution in the curcumin group. The MO improved in both the
groups, but significant improvement was seen at the end of 1 month in the intra-lesional
group. TP showed greater recovery on the first month in the intra-lesional group when
compared with the curcumin group.
4.2.10
Polyherbal Formulations
The formulation of the oxitard capsules have been tried in the treatment of OSMF. It contains the extracts of various plants viz., Mangifera indica, Withania somnifera, Daucus
Role of Herbal and Natural Products 69
carota, Glycyrrhiza glabra, Vitis vinifera, Emblica officinalis, and Yashada bhasma; and oils
of Triticum sativum.
Patil et al. [39] evaluated Oxitard capsules in the management of OSMF in 120 subjects
divided equally into the Oxitard and placebo groups. Significant improvements in MO and
TP, reduction in BS, pain associated with the lesion, difficulty in swallowing and speech
were seen in the Oxitard group.
Patil et al. [18] evaluated the efficacy of Oxitard and AV in the management of OSMF in
120 subjects. Subjects were divided equally into Oxitard (two capsules twice daily) and AV
groups (5 mg topical gel thrice daily). Significant improvements in MO, TP, pain associated
with the lesion, difficulty in swallowing, and speech were in favor of the Oxitard group.
However, there was no difference in the improvement of BS between the groups.
4.2.11
Ayurvedic Formulations
PRAK–20 is an herbo-mineral combination of 19 herbs having diverse actions like antifibrotic, anti-inflammatory, and immunomodulatory properties. It contains extracts of
“Zingiber officinale, Piper nigrum, Piper longum, Terminalia chebulia, Termnallia bellirica,
Emblica officinalis, Plumbago zeylanica, Cyperus rotundus, Picrorrhiza kurroa, Cedrus deodara, Embellia ribes, Saussuria lappa, Curcuma longa, Berberis aristata, Baliospermum montanum, Holarrhena antidysentrica, Piper longum, Ipomoea turpethum, Boerhavia diffusa”
along with ferric oxide.
Rajeshwari and Jadhav [40] conducted a clinical study in 40 subjects with OSMF who
were divided into the garlic group (two pearls; thrice daily) and PRAK-20 group (500 mg,
three times a day). Both the groups showed a significant reduction in BS and improvement
in MO and TP. The garlic group had better reduction in BS, while PRAK-20 showed in all
other parameters.
Dash and Sharma [41] conducted an open-label non-randomized trial with ayurvedic
approach in 30 OSMF patients. They were treated with MukhaPralepa (external application) with turmeric and AV followed by kaval (gargling) with Dashamulataila for 1 month
and followed for 1 month. A significant relief in all signs and symptoms with improvement
in MO was seen.
Patel et al. [42] evaluated the effect of ayurvedic treatment protocol in an open-label
non-randomized trial with black box design in OSMF patients. “Koshthashuddhi (mild
purgation) and ShodhanaNasya (errhine therapy); Pratisarana (external application) with
Madhupippalyadi Yoga, Kavala (gargling) with Ksheerabala Taila and internally Rasayana
Yoga” were given for 2 months and followed for 1 month. Significant relief in almost all
signs and symptoms and improvement in MO were seen.
4.2.12
Conclusion
OSMF has been treated with a variety of therapeutic modalities with natural and allopathic
combinations of topical, systemic, or intra-lesional injections, habit cessation, physiotherapy exercises, and surgical modalities. There is a high heterogeneity among the studies and
the participants as well. OSMF has a spectrum of clinical outcomes due to which there is
heterogeneity in the assessment of subjective and objective criteria. This makes comparison of treatment modalities and evaluating their clinical effectiveness very difficult. Very
70 Natural Oral Care in Dental Therapy
few studies exist that have used only natural products for the treatment of OSMF. Most
studies emphasized habit cessation before the initiation of treatment. Also, the participants
in most of the studies have diverse symptoms with different clinical staging. This becomes
a daunting task for the researcher or clinician or health care provider to understand the
effectiveness of the interventions used. Many studies used natural products in conjunction
with standard of care. Currently, there is no consensus on the standard of care in the management of OSMF. Many clinicians rely on periodic intra-lesional steroid injections with
or without hyaluronidase. There is no consensus in the type of steroid, dose, and regimen
leading to numerous possible combinations.
Within the limitations of this review, it is not possible to conclude which natural product would be a suitable alternative in the treatment of OSMF. Natural products do have
a role in the management of OSMF. They can alleviate most of the symptoms of OSMF
without any adverse reactions that are common with the use of intra-lesional steroid injections. However, all natural products do not alleviate all the symptoms of OSMF. Clinicians
and health care providers should carefully understand the spectrum of symptoms in the
patients and then decide the line of treatment. A single protocol may not be feasible for the
management of OSMF with natural products. Further, high-quality studies standardized
studies with patient reported outcomes are recommended.
4.3 Oral Leukoplakia (OL)
4.3.1 Background
The term Leukoplakia should be used to recognize white plaques of questionable risk having excluded (other) known diseases or disorders that carry no increased risk for cancer.
[43]. It is mostly asymptomatic and has a tendency to change into squamous cell carcinoma.
Treatment of OL should emphasize on the elimination of risk factors (tobacco, betel quid,
alcohol), superimposed candida infection over the lesion, etc. [44]. Up to 60% of the lesions
regress or totally disappear after cessation of the habit [45]. In view of the evidence linking
alcohol, tobacco, betel nut, and diet to the development of potentially malignant and malignant oral epithelial lesions, such deleterious habits should be discouraged [45]. A recent
Cochrane review [46] have included only four trials, which had interventions with herbal
extracts. However, we have reviewed most of the existing literature related to natural and
herbal products to get an overall glimpse of the current status of the same.
4.3.2 Green Tea and Extracts
Epigallocatechingallate (EGCG) is a polyphenol, which has antioxidant and chemopreventive properties. Li et al. [47] conducted a randomized double blind trial in 59 patients
with OL. They were randomly divided into mixed tea group (3 g/day oral capsules, in four
divided doses, plus 10% mixed tea ointment in glycerine topically) or placebo group (placebo
plus topical glycerine). The size of oral lesions decreased in 37.9% and increased in 3.4% in
the mixed tea group. The size decreased in 10.0% and increased in 6.7% in the placebo group.
Tsao et al. [48] conducted a phase II trial with green tea capsules on 41 patients
with oral premalignant lesions. They were randomized to receive green tea extract at
Role of Herbal and Natural Products 71
concentrations of 1.0, 0.75, and 0.5 g/m2 or placebo, three times daily for 12 weeks. The
clinical response rate was higher in all the patients who received green tea extracts (50%)
versus placebo (18.2%). Patients receiving higher dosage (1 and 0.75 g/m2) had higher
response than lower dose group and placebo.
Yoon et al. [49] used “swish-and-spit” green tea extract mouthwash as an oral cancer chemopreventive agent. They found a detectable level of epigallocatechin-3-gallate in the saliva
after 1 week of treatment. After 1 week of treatment, the immunohistochemical expression
of markers like phosphoactivated epidermal growth factor receptor, cyclooxygenase-2, and
ki-67 have been found in lower levels than baseline.
4.3.3 Beta-Carotene (βC)
Stich et al. [50, 51] conducted a trial to evaluate vitamin A/βC supplementation in 33 betel
quid chewers. They received capsules of retinol (1,00,000 IU/week) and βC (3,00,000 IU/
week) for 3 months. The frequency of micronucleated buccal mucosa cells was decreased,
and no difference was seen in patients not receiving vitamin pills.
Stich et al. [52] administered vitamin A (60 mg/week to 6 months) or βC (2.2 mmol/
week) in Indian fishermen who chewed betel quid + tobacco before and during the course
of the study. The vitamin A group had complete remission of OL in more than half (57%)
and reduction of micronucleated cells in almost all the participants. The βC group had
remission in only 14.8% and reduction of micronucleated cells in almost all the participants. New OL formation was completely suppressed by vitamin A with only 50%
suppression by βC in the study period. After cessation of the treatment, OL reappeared,
and there was an increase in the frequency of micronuclei, and nuclear textures reverted
baseline features.
Stich et al. [53] conducted a trial in Indian fishermen who chewed betel quid + tobacco
and had OL. Participants were divided into βC (180 mg/week, 6 months), βC + vitamin A
(180 mg/week + 1,00,000 IU/week, 6 months), and placebo groups. At 3 months, no significant difference in the remission rates of OL was seen among the groups. Remission rates of
OL in βC and βC + vitamin A groups differed significantly than the placebo. βC + vitamin A
followed by βC had strong inhibition of new lesions than the placebo. βC and βC + vitamin
A were successful in the remission and inhibition of new OL in continuous betel quid +
tobacco chewers.
Garewal et al. [54] conducted a phase 2 trial of βC in 24 patients with OL. Two patients
had complete and 15 had partial remission with no significant toxicity after administration
of βC for 3 months.
Toma et al. [55] conducted a phase 2 trial of βC in 23 patients of OL. Patients have not
modified any of their tobacco or alcohol habits. Eighteen patients completed follow-ups
out of which six, two, and three patients showed complete, partial, and minimal response
to treatment. No signs of toxicity were detected, but nine cases had side effects like orange
pigmentation of palms and face, elevated cholesterol, renal colic, cephalgia, burning sensation, hypersensitivity of oral mucosa, and hypersalivation were observed.
Sankaranarayanan et al. [56] conducted a randomized controlled trial to evaluate vitamin A or βC in the management of OL. Subjects were divided into oral vitamin A (retinyl
acetate 300,000 IU/week for 1 year) or βC (360 mg/week for 1 year) or placebo groups.
There was a significant difference in the complete regression rates in vitamin A, βC, and
72 Natural Oral Care in Dental Therapy
placebo (52%, 33%, and 10%, respectively). Relapse after cessation of the supplementation
was seen in two-thirds of vitamin A and half of βC groups.
Liede et al. [57] studied the effect of supplements of alpha-tocopherol or βC on the
prevalence of oral mucosal lesions in smokers. A total of 409 subjects were divided into
alpha-tocopherol (50 mg/day) or βC (20 mg/day), both alpha-tocopherol + βC or placebo
groups. No significant differences in the prevalence of oral mucosal lesions.
Garewal et al. [58] conducted a randomized double blind trial duration to evaluate the
response and the need for maintenance therapy in subjects responded to βC for the management of OL. Initially, subjects were asked to use βC for 6 months to see the response
rates. Responders were randomized βC or placebo groups for 1 year. At 6 months, 52% of
the subjects had a clinical response. Relapse was seen only in 2 of 11 in the βC and 2 of 12
in the placebo groups.
Barth et al. [59] studied the effect of βC, and vitamins E and C on 24 patients with OL
and 24 patients after radical resection of a primary oral cancer. With the intervention, the
redifferentiation of the oral mucosa was intense when there was cessation of alcohol and
tobacco than with the persistence of the alcohol and tobacco abuse. However, long-term
prevention does not seem to be effective.
Nagao T et al. [60] conducted a randomized, double-blind controlled trial to evaluate the
use of low-dose βC combined + vitamin C in the management and prevention of malignant
transformation of OL. A total of 46 were randomly divided into βC + vitamin C or placebo groups with supplementation for 12 months. There was no significant difference in the
response rate in the study (17.4%) and placebo (4.3%) groups. Within the 5-year follow-up,
two in the study and three in the placebo progressed to malignancy.
4.3.4 Lycopene
Lycopene appears to be a very promising antioxidant as a treatment modality in OL and can
protect cells against damage. It has an antioxidant property, modify intercellular exchange
junctions, and has a protective role in dysplasia [61].
Singh et al. [62] studied the efficacy of different concentrations of lycopene in the treatment of OL with a placebo in 58 OL patients who were randomly divided into lycopene
(8 mg/day), lycopene (4 mg/day), and placebo. The mean response of 80%, 66.25%, and
12.5% was seen in lycopene 8 mg, lycopene 4 mg, and placebo, respectively, which was
highly significant in favor of lycopene.
Patel et al. [63] conducted a randomized placebo controlled trial to evaluate antioxidants
(lycopene + vitamin E + selenium) in the management of 41 OL subjects. Subjects receiving
antioxidants showed significant clinical (lesion size) and histological improvements compared with the placebo. Complete and partial improvement was seen in 5 and 14 subjects in
group A, while only 3 showed partial improvement.
4.3.5 Curcumin
Cheng et al. [64] conducted a phase-I study in patients with any of the five different premalignant conditions among 25 participants. Histologic improvement was seen in two out
of seven patients of OL. They reported no toxicity and adverse effects. Kuriakose et al. [65]
conducted a randomized double-blind placebo-controlled (phase IIB) trial among 223 OL
Role of Herbal and Natural Products 73
subjects randomized into curcumin and placebo groups. A significantly higher proportion of clinical response was observed in the curcumin group (67.5%) compared with the
placebo group (55.3%) with a durable response in both groups and no relapse at 6 months
follow-up. Among partial responders, continued therapy has not yielded any benefit.
4.3.6 Miscellaneous
4.3.6.1 Alpha-Tocopherol
Benner et al. [66] also studied the micronuclei frequency with α-tocopherol supplementation in OL patients. Supplementation showed a significant reduction in the mean micronuclei frequencies in lesions in the normal mucosa.
Benner et al. [67] conducted a phase II trial of α-tocopherol in the management of 43
OL. A total of 46% had clinical and 21% had histologic response, respectively.
Kaugars et al. [68] studied antioxidant supplementation (βC + ascorbic acid +
α-tocopherol) for 9 months in 79 patients with OL. Clinical improvement was seen in 55.7%
and is more evident in subjects with reduced habits.
4.3.6.2 Chinese Herbs
Zeng Sheng Ping [69] (ZSP) is a mixture of six medicinal herbs. Sun et al. [69] studied the
chemopreventive action of ZSP mixture among animal models and human patients. With
favorable results, they compared ZSP with placebo in a randomized controlled trial among
subjects with OL. The lesion reduced in size significantly in the ZSP group (67.8%) compared with the placebo (17%).
4.3.6.3 Bowman–Birk Inhibitor Concentrate (BBIC)
It is a protease inhibitor which showed a chemopreventive activity in vitro in animal and
clinical trials (phase IIa and IIb). Armstrong et al. [70] conducted a clinical trial (phase IIa)
with BBIC in 32 subjects with OL for 1 month. A total of 31% showed clinical response
(two complete and eight partial). The lesion area decreased significantly after 1 month
when compared to the baseline with an overall decrease of 24.2% in the lesion at all doses.
This was followed by a phase IIb placebo-controlled trial by Armstrong et al. [71] with
100 subjects randomized into BBIC or placebo. Only 89 subjects completed the 6 months
follow-up. Both the groups showed significant decrease in the mean lesion area with no
significant difference.
4.3.7 Conclusion
OL is asymptomatic unlike other potentially malignant disorders. The aim of the diagnosing
and treatment is to prevent its transformation into malignancy. Many approaches have been
tried in the management of OL that includes topical and systemic medications, surgery, cessation of habits, and only surveillance. There is no stringent consensus on the standard of
care, and it is highly dependent on the decision of the clinician or the health care provider.
All these established treatment protocols have their own advantages and disadvantages,
74 Natural Oral Care in Dental Therapy
which also has a role in the decision process of the treatment. Natural products have been
tried in the treatment of OL with variable efficacy rates and minimal or no adverse effects.
They have been supplemented topically or systemically with variable, follow-up time periods with variable level of emphasis on habit cessation, which is a strong predictor for lesion
regression. Since the condition is asymptomatic, not many clinical outcomes are recorded
during the trials. Moreover, many studies were still in the early phases of the clinical trials
without a comparative group. Hence, it is difficult to conclude the efficacy of these natural
products. High-quality studies are recommended to have conclusive evidence in the efficacy of these products over long-term follow-up.
4.4 Oral Lichen Planus (OLP)
OLP is a chronic T-cell-mediated autoimmune disease with [72] substantial fluctuation in
disease activity within and between individuals [73]. Various treatment modalities with different regimens have been tried in the management of OLP but have not showed complete
resolution.
Choonhakaran et al. [74] compared AV and placebo in randomized, double-blind, controlled trial for the management of 54 OLP. They were randomized into AV gel or placebo.
At the end of 8 weeks, a significantly higher proportion of good response was observed in
the AV group (81%) compared with the placebo (4%). Complete remission was seen in two
patients of the AV group. There was complete disappearance of burning pain in 33% treated
with AV gel and in one in the placebo group, which was significant.
Salazar-Sanchez et al. [75] conducted a randomized controlled trial to compare topical
AV and placebo among 64 OLP patients. No significant differences in mean pain scores
were recorded between both groups at the end of 6 and 12 weeks. Complete pain remission was seen in 31.2% and 61% at 6 and 12 weeks in the AV group, while only 17.2% and
41.6% were seen in placebo group. There was significant difference in the total score of oral
health-related quality of life and psychological disability domain in favor of the AV group.
Mansourian et al. [76] compared AV mouthwash with triamcinolone among 46 OLP
patients randomly divided into AV or triamcinolone groups. Both the groups significantly
reduced VAS, Thongprasom scores, and size of the lesions after treatment and after discontinuation of the treatment (2 months). In both the groups, three-fourths of the patients
showed various degrees of healing at the end of follow-up.
Reddy et al. [77] conducted a randomized clinical trial to evaluate the effectiveness of the
AV gel over triamcinolone acetonide in 40 OLP patients. Subjects had erosive and atrophic
lichen planus. Over 8 weeks of treatment, it was seen that the AV group showed more effectiveness than triamcinolone with respect to clinical signs and symptoms.
Sawaarn et al. [78] conducted a randomized placebo-controlled trial with systemic
lycopene in the management of OLP patients. They were randomly divided into lycopene
(8 mg/day) and placebo. Reduction in BS was higher in the lycopene group (84%) than in
the placebo group (67%). Among the lycopene group, all patients showed more than 50%
benefit, while such benefit is seen only in 10 patients of the placebo group.
Singh et al. [79] used turmeric extracts in the form of ointment to treat OLP. At the end
of 3 months, almost all the patients had complete remission with respect to various symptoms like BS, intolerance to spices, redness, ulceration, and striae. Nine of the 10 patients
Role of Herbal and Natural Products 75
showed healing at the end of 3 months. With respect to the Thongprasom sign score, 9 of
the 10 patients reported a score of 0 at the end of 3 months.
Thomas et al. [80] compared 1% curcumin gel with 0.1% triamcinolone acetonide in
the management of OLP. A total of 75 subjects were divided into triamcinolone, curcumin gel (thrice daily), and curcumin gel (six times daily). All groups showed significant
reduction in the BS, erythema, and ulceration with maximum reduction in triamcinolone. Curcumin gel when applied six times daily was beneficial than when applied three
times daily.
Vickers and Woodcock [81] used raspberry leaf extract to treat 10 OLP patients over
6 months. There was significant reduction in pain intensity and clinical features of reticulation, erosion, and ulceration at the end of 6 months. No adverse clinical or systemic
effects were observed in the subjects.
Agha-Hosseini et al. [82] conducted a randomized placebo-controlled trial to evaluate
purslane in the treatment of in 37 OLP patients. All subjects were divided into purslane
or placebo for 3 months. Partial to complete clinical improvement was seen in 83% of the
participants in purslane, while only 17% had partial improvement in the placebo group.
Similarly, with respect to the VAS scores, partial to complete response was seen in all the
purslane group patients, while only 71% showed only partial response in placebo group.
4.4.1 Conclusion
OLP has been treated with mainly topical steroids as the first line of treatment. There was
a limited number of studies on the treatment of OLP with herbal or natural extracts. OLP
has many clinical outcomes due to which there is heterogeneity in the assessment of subjective and objective criteria. Hence, evaluating their clinical effectiveness is difficult for the
researcher or clinician or health care provider. A recent Cochrane review [73] included 28
studies but have included two trials that were done with AV. The review concluded with an
insufficient evidence for any of the treatments that have been used.
Within the limitations of this review, it is not possible to conclude the effectiveness of
these natural products as a suitable alternative. Natural products might alleviate symptoms
of OLP without any adverse reactions. Further, studies that are high quality with standardized outcomes and emphasis on patient-reported outcomes are needed with long-term
follow-ups and adverse effects.
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Part II
STUDIES OF PLANTS USED
IN DENTAL DISEASE
5
Studies on the Anticariogenic Potential
of Medicinal Plant Seed and Fruit Extracts
Disha M. Patel, Jenabhai B. Chauhan* and Kalpesh B. Ishnava†
Ashok and Rita Patel Institute of Integrated Study and Research in Biotechnology and Allied Sciences
(ARIBAS), New Vallabh Vidyanagar, Gujarat, India
Abstract
Oral diseases are common health problems worldwide. There is a global need for the alternative, safe,
and effective treatment for oral diseases. Compounds from medicinal plants have been proven to be
an effective alternative. To screen the anticariogenic activity, organic solvents (hexane, ethyl acetate,
methanol) and aqueous extracts of 19 medicinal plant seeds and fruits were assayed against five
different cariogenic bacteria by agar well diffusion assay and MIC. ethyl acetate (E), methanol (M)
and aqueous extract of Quercus infecteria exhibited significant growth inhibition in all the selected
cariogenic bacteria, which is comparable with the standard antibiotic drug erythromycine. The MIC
values of 78, 625, and 156 µg/mL were obtained against L. casei when Q. infectoria (E), P. granatum
(E), and Q. infectoria (M) extracts were used. Ethyl acetate and methanolic extract of Q. infectoria contains tannins, cardiac glycosides, steroids, terpenoids, phenolic compounds, and alkaloids.
Bioactive compounds from all the effective crude extracts were separated using TLC and localized
bioautographically. Ethyl acetate and methanolic extract of Q. infectoria were found to be useful for
clinical evaluation and development of potential alternatives for the treatment against cariogenic
bacteria responsible for dental caries.
Keywords: Dental disease, medicinal plants, anticariogenic activity, TLC-Bioautography
5.1 Introduction
Oral diseases are common and a growing problem across the globe. There are many bacteria present in the oral cavity, and a few of them are responsible for oral diseases especially
dental caries. In Asia and worldwide, dental caries are most prevalent in adults and children. It is the major pathological cause of tooth loss in children [1]. Dental caries affect all
the age groups, but the percentage varies. In India, one of two persons/individuals experience dental caries.
The human oral cavity contains both Gram-positive and Gram-negative bacilli as well as
spirochetes. They are distributed on various sites in the human mouth [2]. Gram-positive
*Corresponding author: jbc109@yahoo.co.in
†
Corresponding author: ishnavakb203@yahoo.com
Durgesh Nandini Chauhan, Prabhu Raj Singh, Kamal Shah, and Nagendra Singh Chauhan (eds.)
Natural Oral Care in Dental Therapy, (83–96) © 2020 Scrivener Publishing LLC
83
84 Natural Oral Care in Dental Therapy
bacteria include cocci (facultative and anaerobic) and rods (facultative and anaerobic).
Gram-negative bacteria include both streptococci (S. mutans, S. sanguis, S. mitis, S. salivarius, and S. mitis) and staphylococci. The proportions of each group of bacteria vary at
different sites such as plaque, tongue, saliva, and gingival region. The bacterial composition also varies with age; for example, at the age of 6–9 months in humans, the oral cavity
contains a large numbers of Streptococcus salivarius (98% of the total bacteria). Once teeth
appear, the S. mutans and S. sanguis colonize the teeth surface (non-epithelial) and form a
dental plaque or biofilm [3]. The oral flora of humans may harm their host since some of
these bacteria are parasites or opportunistic pathogens. These bacteria also enter the bone,
lungs, brain, and breasts through wounds created by dental manipulation or treatments [4].
Though plants are common in traditional health practice, there is a growing concern and
use of plant extracts and plant-derived compounds for the treatment of different oral/dental
conditions, namely, toothache, dental caries, ulcerative gingivitis, gingivitis, mouth ulcers,
oral thrush, swollen tonsils, black tongue, and tonsillitis [5]. Common plants in the field
include Citrus aurantifolia, Xylopia aethiopica, Aframomum melegueta, and Piper guineense.
For ordinary oral hygiene in the morning, roots or stems of certain plants are used to make
brush-like ends to clean the teeth [6]. The individual chewing sticks has been proven to
have variable activity against different oral microbial flora. The presence of benzoic acid
derivatives of Zanthoxylun zanthoxyloides is attributed to antimicrobial action [7]. The phenolic acids and alkaloids (canthin, berberine, and chelerythrine) are active at pH 5 and pH
7.5, respectively. Roots of certain medicinal plants contain anticariogenic compounds that
are active at both alkaline pH and acidic pH. Tella (1976) reported that the root of Vernonia
amygdalina is effective against gingivitis and toothache [8].
Many authors reported the activity of plant seeds against cariogenic and other bacteria like Azadirachta indica [9], Quercus infectoria [10], and Areca catechu [11]. In order
to preserve the teeth, coloring or blackening of the teeth is done using plants, sometimes
up to 1 year. This, in turn, helps in controlling dental caries and keeping the teeth strong
and healthy. Examples of blackening plant species include Duroia hirsute, Neea parviflora
(Family—Nyctaginaceae), Manettia divaricata, and Manetta glandulosa. It was reported that
the cacao bean husk extract significantly reduces the growth rate with 69–72% reduction
and inhibited synthesis of insoluble glucan in S. mutans. It also inhibits sucrose-dependent
adhesion in S. mutans and S. sobrinus to a glass surface with 85% inhibition at >5 mg ml−1
concentration under in vitro conditions [12]. In vivo experiments in healthy rats infected
with the above bacteria showed that the cacao bean husk extract exerted significant cariostatic activity. Ethanolic extract of flower of Helichrysum italicum (Compositae) exerted
antimicrobial activity against S. mutans, S. sanguis, and S. sobrinus [13]. This extract, in the
presence of dextran, reduced cell surface hydrophobicity, adherence to glass, and cellular
aggregation of S. mutans.
There are many studies on the activity of plant extracts and products against a wide
variety of microbial pathogens of the oral cavity. Some studies also focused on the ability
of plant-derived products to inhibit the formation of dental biofilms by interfering and
reducing the adhesion of microbial pathogens to the tooth surface, a primary event in the
formation of dental plaque and the progression to tooth decay and periodontal diseases. It
has been demonstrated that crude plant extracts and purified phytochemicals act through
cidal activity (inhibit any or all stages) or interfere with adherence/aggregation/biofilm formation and inhibit the production of glycolytic acid in cariogenic bacteria. Compared with
Anticariogenic Potential of Medicinal Plants 85
seed extracts, there were more number of reports on antibacterial activity of aerial parts of
the leaves, stem, flowers, roots, and rhizome seed extracts.
Screening for various ethano-botanical plants were undertaken in Gujarat, India, against
common cariogenic bacteria responsible for oral disease/dental caries, and specific plant
part extracts were characterized for their anticariogenic potential [14–20]. Characterization
of bioactive compounds responsible for anticariogenic activity was also performed from
various plant part extracts [21, 22]. Some studies also focused on the anticariogenic activity
of seed protein and oils [23, 24]. There is a report on herbal formulation against anticariogenic activity [25]. The present study was undertaken to screen the anticariogenic activity
of selected medicinal plants seed extracts and fruit extract (only Querus infectoria) against
a group of cariogenic bacteria.
5.2 Materials and Methods
5.2.1 Plant Materials
Most of the seed materials were procured from the local market of Vidyanagar and
Vadodara, Gujarat. Seeds of three plants (Andrographis peniculata, Cassia tora, and Solanum
surattense) were a gift by Dr. Ram Kumar, Department of Medicinal and Aromatic Plants,
Anand Agriculture University (AAU), Anand. Some of the plant seeds were collected from
a botanical garden located in our institutional campus, New Vallabh Vidyanagar. The identity of plant specimens was confirmed through plant taxonomist Dr. Ishnava of our institute. Details of the plant materials are given in Table 5.1.
5.2.2 Preparation of Plant Seed and Fruit Extracts
The seeds and fruits of all the selected plants were thoroughly washed with distilled water.
It was surface sterilized using sodium hypochlorite (10%), rinsed with sterile distilled water,
and air dried under laminar air flow. The powder of the plant materials was made using a
household electric grinder, and 50 g of this materials was mixed in 125 mL of solvent (hexane). The content was kept on a shaker (130–140 rpm) for 24 h at room temperature. The
extract was then filtered using Whatman filter paper. The resulting filtrate was transferred
to glass petri-plates and dried aseptically.
The methanol, ethyl acetate, and aqueous extract of all the plants were prepared as
described above. The resultant dried material from petridishes was stored in an eppendorf
tube and was used for the anticariogenic activity screening.
5.2.3 Cariogenic Bacterial Strains
Bacteria causing dental caries/tooth decay used in this study were purchased from
Microbial Type Culture Collection (MTCC), Chandigarh. Freeze-dried pure culture first
revived as per MTCC specified growth conditions and preserved as glycerol stocks. Five
cariogenic bacteria includes Staphylococus aureus (MTCC-96), Lactobacillus acidophilus
(MTCC-*447), Streptococcus mutans (MTCC-890), Lactobacillus casei (MTCC-1423), and
Actinomyces viscosus (MTCC-7345).
86 Natural Oral Care in Dental Therapy
Table 5.1 Seeds and fruits used for anticariogenic activity.
Sr. no.
Botanical name
Common name
Family
Collection site
1
Piper nigrum L.
Meri
Piperaceae
Vadodara
2
Areca catechu L.
Sopari
Arecaceae
Vadodara
3
Trigonella foenum-graceum
L.
Methi
Papilionaceae
Vadodara
4
Andrographis paniculata
(Burm.f.) Wall.
Kariyatu
Acanthaceae
AAU, Anand
5
Coriandrum sativum L.
Dhanadal
Apiaceae
Vidyanagar
6
Derris indica (Lam.)
Bennet.
Karanj
Papilionaceae
IICP Garden
7
Juglans regia L.
Akhrot
Juglandanceae
Vidyanagar
8
Prunus amygdalus Batsch.
Badam
Rosaceae
Vidyanagar
9
Punica granatum L.
Dadam
Punicaeae
Vidyanagar
10
Mimusops elengi L.
Borsali
Sapotaceae
IICP Garden
11
Madhuca indica J. F. Gmel.
Mahudo
Sapotaceae
IICP Garden
12
Sesamum indicum L.
Tal
Pedaliaceae
Vidyanagar
13
Cassia tora L.
Kuvandio
Caesalpiniaceae
AAU, Anand
14
Sapindus laurifolius Vahl.
Aritha
Sapindaceae
IICP Garden
15
Azadirachta indica A.juss.
Limdo
Meliaceae
IICP Garden
16
Solanum surattense Burr.f.
Bhoyringni
Solanaceae
AAU, Anand
17
Cassia fistula L.
Garmalo
Caesalpiniacee
IICP Garden
18
Quercus infectoria Oliv.
Mayafal
Fagaceae
Vadodara
19
Elettaria cardamomum (L.)
Maton
Elaichi
Zingiberaceae
Vadodara
5.2.4 Preparation of Inoculums
In order to make fresh bacterial cultures, loopful of bacterial cell suspension streaked in to
specific liquid growth media (Hi-media) followed by incubation at optimal temperature.
This step was simultaneously done for each bacteria. Cell growth (1 × 108 bacterial cell
count per mL) was quantified by comparing it with 0.5 McFarland turbidity standard, and
it is maintained throughout the experiment [26].
Anticariogenic Potential of Medicinal Plants 87
5.2.5 Anticariogenic Activity Screening of Plant Extracts
5.2.5.1 Agar Well Diffusion Assay
Agar well diffusion assay used to access antibacterial activity of seed and fruit extracts. The
stock of each plant extract was prepared by suspending 100 mg of solvent-extracted dried
materials in 1 ml of dimethyl sulfoxide (DMSO). Petriplates were thoroughly washed using
detergent, dried and sterilized using autoclave at 15 lbs pressure for 15 min and used for the
reparation of agar plates. Approximately 25 mL of sterilized selective medium was poured in to
each petridish and solidified at room temperature and incubated overnight at 37°C for sterility
checking. Agar plates were first divided into four equal parts and labeled with H (Hexane), E
(Ethyl acetate), M (Methanol), and D (Distilled water) and specific bacteria. The center of the
plate was labeled with the serial number of the plant. One hundred microliters (100 µL) of fresh
bacterial culture having 108 Cells/mL was spread on agar plates using a glass spreader. Using a
sterile cork borer, a well of 10-mm diameter was made in the above petri plates, and it was then
filled with 100 µL of the respective plant extracts. Agar plates were kept for half an hour at 4°C
in a refrigerator for pre-diffusion and then incubated at 37°C/specified temperature for 24 h or
more as per the strain of the bacteria. The actual zone of inhibition was measured and recorded.
Commercially available standard antibiotics Cefadroxil, Tetracycline, and Erythromycine
(100 µg/mL) was used as a positive control, whereas 100% DMSO was used as the negative
control. The experiment was set up in three replicates and repeated twice.
5.2.5.2 Determination of Minimum Inhibitory Concentration (MIC)
Minimum inhibitory concentration was evaluated by twofold serial broth dilution method
and using 2,3,5-triphenyl tetrazolium chloride as described by Ishnava et al., 2003 and
Barad et al., 2014 [19, 22, 26]. Plant extracts with greater than 10-mm zone of growth inhibition were subjected to determination of MIC. Bacteria-specific broth medium was used
for preparing the inoculums and dilutions. The bacterial cell density (1 × 108 Cells /mL) was
maintained uniformly throughout the experimentation.
5.2.6 Preliminary Phytochemical Analysis
Presence of phytochemicals in the potential plant extracts was determined according to
Parekh and Chanda, 2008 [28].
5.2.7 Analytical Thin Layer Chromatography
It is performed to find a suitable solvent system for the development of chromatogram.
The details of the solvent system are finalized for different plants using ready-made TLC
plates, silica gel 60, 0.25 mm, and F254 plate (Merck). The solvent systems for Areca catechu [methanol:benzene (4:1)], Punica granatum [ethyl acetate:methanol:distilled water
(1:5:1)], Cassia tora [ethyl acetate:methanol:distilled water (6:1:0.5)], Quercus infectoria
[ethyl acetate:methanol:distilled water (a) 2:10:0.5 (b) 5:3:0.5], and Elettaria cardamomum
[Methanol: chloroform (4:1)] were tested.
88 Natural Oral Care in Dental Therapy
5.2.8 TLC—Bioautography
Among the 19 plant seeds and fruit extracts tested for anticariogenic activity, only 1 plant
extract showed the highest inhibition zones against Actinomyces viscosus and Staphylococcus
aureus, 3 plant extracts showed inhibitory activity against Streptococcus mutans, and 2 plant
extracts each for Lactobacillus casei and Lactobacillus acidophilus were subjected to bioautography. TLC—Bioautography was performed as per Ishnava et al., 2013 and Rajput and
Ishnava, 2017 [20, 22].
5.3 Result and Discussion
The distilled water, ethyl acetate, hexane, and methanolic extracts were assayed against five
selected cariogenic bacteria by agar well diffusion assay. None of the selected cariogenic
bacterial growth was inhibited by dimethyl sulfoxide.
The antimicrobial activity of the different solvent extracts of the plant seeds and fruits
showed a variable pattern with the highest efficacy in the ethyl acetate extract followed by
methanol, aqueous, and hexane extracts (Table 5.2). One of the important observations
in the present study is that ethyl acetate, methanol, and aqueous extract of Quercus infecteria exhibited significant growth inhibition in all the selected cariogenic bacteria except
Actinomyces viscosus, which is comparable with the standard antibiotic drug erythromycin
(Table 5.2).
The result obtain from the hexanolic extract of plant seeds showed that only 5 plants
(26%) out of the total plants (19) are active against Staphylococcus aureus (3–5 mm zone),
Actinomyces viscosus (8–9 mm zone), and Streptococcus mutans (5–8 mm zone). No growth
inhibition was found in Lactobacillus acidophilus and Lactobacillus casei (Table 5.2). The
plants showing growth-inhibitory activity include Piper nigrum, Areca catechu, Trigonella
foenum-graceu, Derris indica, and Elettaria cardamomum. The zone of inhibition (9 mm)
was found in A. viscosus when A. catechu and E. cardamomum extracts were used (Table
5.2).
Comparatively the highest number of plants (47%) showed growth inhibition when
seeds of the selected plants were extracted with ethyl acetate (Table 5.2). The plant materials
showing zone of inhibition includes, P. nigrum, A. catechu, T. foenum-graceu, Punica granatum, Madhuca indica, Cassia tora, Cassia fistula, E. cardamomum, and Quercus infectoria.
Growth of all the cariogenic bacteria was inhibited with a maximum zone of inhibition of
13, 20, 13, 18, and 18 mm in AV, SM, LA, LC, and SA, respectively (Table 5.2). These zones
of inhibition are highly significant and comparable with one of the standard antibiotic
erythromycin. One of the interesting finding is that the ethyl acetate extract of Q. infectoria
exhibited the highest zone of inhibition in SM, LA, LC, and SA compared to the hexane,
methanol, and aqueous extracts (Table 5.2 and Figure 5.1). Only E. cardamomum was found
effective against A. viscosus among the 19 plant extracts evaluated in the present study. The
effective plant extracts were subjected to MIC determination.
Methanolic seed extracts of 8 plants (P. nigrum, A. Catechu, Derris indica, Juglans regia,
P. granatum, M. indica, C. tora, and Quercus infectoria) from a total of 19 plants exhibited variable growth inhibition in SM, LA, LC, and SA with growth inhibiting ranges of
5–19 mm, 3–13 mm, 2–17 mm, and 2–17 mm, respectively (Table 5.2). None of the plant
Table 5.2 Anticariogenic activity of solvent extracts of seeds and fruit.
Bacteria
Zone of inhibition (in mm)
Hexane extract
Ethyl Acetate extract
Methanol extract
Aqueous extract
Plant name
A
V
S
M
L
A
L
C
S
A
A
V
S
M
L
A
L
C
S
A
A
V
S
M
L
A
L
C
S
A
A
V
S
M
L
A
L
C
S
A
1
Piper nigrum
–
–
–
–
05
–
05
–
–
–
–
–
–
–
02
–
–
–
–
02
2
Areca catechu
09
08
–
–
03
–
–
–
01
05
–
10
03
08
08
–
10
03
08
08
3
Trigonella
foenum-graceum
08
–
–
–
05
–
–
–
–
01
–
–
–
–
–
–
–
–
–
–
4
Andrographis
paniculata
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
5
Coriandrum sativum
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
6
Derris indica
–
05
–
–
05
–
–
–
–
–
–
05
–
02
–
–
05
–
02
–
7
Juglans regia
–
–
–
–
–
–
–
–
–
–
–
–
–
08
–
–
–
–
08
–
8
Prunus amygdalus
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
9
Mimusops elengi
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
10
Punica granatum
–
–
–
–
–
–
–
–
11
–
–
–
–
09
–
–
–
–
09
–
11
Madhuca indica
–
–
–
–
–
–
–
–
03
–
–
–
–
03
–
–
–
–
03
–
12
Sesamum indicum
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
13
Cassia tora
–
–
–
–
–
–
10
–
02
05
–
–
03
03
–
–
–
03
03
–
(Continued)
Anticariogenic Potential of Medicinal Plants 89
Sr. No.
Bacteria
Zone of inhibition (in mm)
Hexane extract
Ethyl Acetate extract
Methanol extract
Aqueous extract
Sr. No.
Plant name
A
V
S
M
L
A
L
C
S
A
A
V
S
M
L
A
L
C
S
A
A
V
S
M
L
A
L
C
S
A
A
V
S
M
L
A
L
C
S
A
14
Sapindus laurifolius
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
15
Azadirachta indica
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
16
Solanum surattense
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
17
Cassia fistula
–
–
–
–
–
–
08
10
02
09
–
–
–
–
–
–
–
–
–
–
18
Quercus infectoria
–
–
–
–
–
–
20
13
18
18
–
19
13
17
17
–
19
13
17
17
19
Elettaria cardamomum
09
–
–
–
–
13
–
–
07
–
–
–
–
–
–
–
–
–
–
–
20
Tetracycline
–
28
28
41
26
–
28
28
41
26
–
28
28
41
26
–
28
28
41
26
21
Cefadroxil
–
12
36
41
31
–
12
36
41
31
–
12
36
41
31
–
12
36
41
31
22
Erythromycine
–
15
23
19
19
–
15
23
19
19
–
15
23
19
19
–
15
23
19
19
23
DMSO
–
00
00
00
00
–
00
00
00
00
–
00
00
00
00
–
00
00
00
00
Actinomyces viscosus (AV), Streptococcus mutans (SM), Lactobacillus acidophilus (LA), Lactobacillus casei (LC), Staphylococcus aureus (SA)
90 Natural Oral Care in Dental Therapy
Table 5.2 Anticariogenic activity of solvent extracts of seeds and fruit. (Continued)
Anticariogenic Potential of Medicinal Plants 91
Staphylococcus aureus
Streptococcus mutans
Lactobacillus acidophilus
Lactobacillus casei
Figure 5.1 Anticariogenic activity of Quercus infectoria distilled water (D), ethyl acetate (E), hexane (H), and
methanol (M) extracts.
extracts inhibited the growth of AV (Table 5.2). Unlike the hexanolic extract, the methanolic extract of Q. infectoria remains highly active against all the cariogenic bacteria except
AV, which was once again comparable with the standard antibiotic drug erythromycin.
The growth inhibitory zone of the methanolic extract of Q. infectoria against key bacteria
(S. mutans) responsible for dental caries was 19 mm, which is higher than that of the two
standard drugs, cefadroxil (12 mm) and erythromycin (15 mm) (Table 5.2 and Figure 5.1).
The effective extract showing a zone of inhibition of 10 mm or more was subjected to MIC
determination.
Aqueous or distilled water extract of plant seeds also showed variable growth inhibitory
pattern in selected carcinogenic bacteria (Table 5.2). A total of eight plants showed activity
where Q. infectoria is active against SM, LA, LC, and SA (Table 5.2). Both the extracts of A.
catechu are active against SM, SA, and LC, whereas P. granatum is active against AV, LA, and
LC (Table 5.2). The minimum zone of inhibition was 1 mm in LC by C. tora. The maximum
inhibition zone of 13 mm was exerted by Q. infectoria aqueous extract both in SM and
LC (Table 5.2 and Figure 5.1). Only one plant (P. granatum) exhibited activity against AV,
whereas seven plants exhibited activity against LC (Table 5.2). Recently, due to the development of multiple drug resistance in the human pathogenic organisms by modern pharmaceuticals, there is an increase in the reports related to antimicrobial properties of plants
from all parts of the world [29]. For the development of new antimicrobial drugs from the
plant, it is necessary that the compound should inhibit the growth of pathogen or kill them,
and it should not be toxic to the host cells. Traditionally, various parts of plants supply
affordable medicine to the Indian population and are traditionally utilized for the treatment
of various human diseases. Plant-derived compounds were successfully used to prevent
oral and plaque-related diseases including dental caries [30]. Our result showed that crude
ethyl acetate extract of Quercus infectoria, Cassia tora, Cassia fistula, Punica granatum, and
methanol extracts of Q. infectoria and Areca catechu showed very good anticariogenic activity against L. casei, S. mutans, S. aureus, L. acidophilus, and A. viscosus. Determination of
MIC and phytochemical screening of these extract provides valuable information for drug
discovery.
5.3.1 MIC Value of Effective Plant Extracts
All the selected plant extracts showing maximum zone of inhibition against targeted organisms were subjected to minimum inhibitory concentration (MIC) values and summarized
in Table 5.3.
92 Natural Oral Care in Dental Therapy
Table 5.3 MIC (expressed in µg/ml) of effective seed extracts against cariogenic bacteria.
Bacteria MIC (µg/ml)
Sr. no.
Plant name (Extracts)
AV
SM
LA
LC
SA
2
Areca catechu (M)
–
312
–
–
–
10
Punica granatum (E)
–
–
–
625
–
13
Cassia tora (E)
–
312
–
–
–
17
Cassia fistula (E)
–
–
625
–
–
18
Quercus infectoria (E)
–
312
625
78
156
18
Quercus infectoria (M)
–
312
625
156
625
19
Elettaria cardamomum (E)
625
–
–
–
–
Methanol (M), Ethyl acetate (E).
Determination of the MIC values of ethyl acetate and methanolic extract of seven plants
generated the data where the maximum MIC value was found to be 625 µg/mL and the
minimum value as 78 µg/mL (Table 5.3).
The MIC value of the methanolic extract of E. cardamomum against A. viscosus was
625 µg/mL (Table 5.3). The minimum inhibitory concentration value of 312 µg/mL was
achieved against S. mutans, when ethyl acetate extract of Cassia tora, Q. infectoria and
methanolic extract of Areca catechu, Q. infectoria were used (Table 5.3).
Ethyl acetate extract of C. fistula and ethyl acetate as well as methanolic extract of
Q. infectoria exhibited an MIC value of 625 µg/mL against L. acidophilus (Table 5.3). The
MIC values of 78, 625, and 156 µg/mL were obtained against L. casei when Q. infectoria (E),
P. granatum (E), and Q. infectoria (M) were used (Table 5.3).
The minimum inhibitory concentration values of 156 µg/mL and 625 µg/mL were found
when ethyl acetate and methanolic extracts of Q. infectoria were assessed against S. aureus
(Table 5.3).
5.3.2 Phytochemical Screening and Bioautography
The presence of phytochemical substances like alkaloids, cardiac glycosides, phenolic compounds, tannins, terpenoids, and steroids were tested qualitatively as per Ahmed & Beg,
2001 [29]. The ethyl acetate and methanolic extracts of Q. infectoria contain all these bioactive compounds, whereas in P. granatum, only terpenoids are absent (Table 5.4). Casia
fistula was found positive for alkaloids, steroids, phenolic compounds, and cardiac glycosides. Only terpenoids and phenolic compounds were found positive in E. cardamomum
(Table 5.4).
For the presence of bioactive substances in the ethyl acetate and methanolic extracts
of effective plants, various TLC solvent system were used and standardized using TLC
plates, silica gel 60, 0.25 mm, and F254 plate (Merck). The standardized solvent systems
are Areca catechu—methanol:benzene (4:1), Punica granatum—ethyl acetate:methanol:distilled water (1:5:1), Cassia tora—ethyl acetate:methanol:distilled water (6:1:0.5), Quercus
Anticariogenic Potential of Medicinal Plants 93
Table 5.4 Phytochemical constituents of crude solvent extracts of effective plants.
Sr. no.
Plant name (Extracts)
1
2
3
4
5
6
2
Areca catechu (M)
+
–
–
+
+
–
10
Punica granatum (E)
+
+
+
–
+
+
13
Cassia tora (E)
–
–
+
–
+
+
17
Cassia fistula (E)
–
+
+
+
+
18
Quercus infectoria (E)
+
+
+
+
+
+
18
Quercus infectoria (M)
+
+
+
+
+
+
19
Elettaria cardamomum (E)
–
–
–
+
+
–
Absent = (−); Present = (+); 1 (Tannins), 2 (Cardiac Glycosides), 3 (Steroids), 4 (Terpenoids),
5 (Phenolic Compounds), and 6 (Alkaloids).
infectoria—ethyl acetate:methanol:distilled water (a) 2:10:0.5 (b) 5:3:0.5 and for Elettaria
cardamomum—methanol:chloroform (4:1).
Bioactive substances are successfully separated from crude solvent extracts using TLC.
For the determination of single or multiple substances in the various plant extracts, they
were exposed under iodine vapor and UV rays (254 nm). The yellow brown spots and blue
fluorescence was obtained when TLC chromatogram was exposed to iodine vapor and UV
light, respectively.
When TLC-bioautography was performed to identify the bioactive substances associated
with anticariogenic activity, the chromatograms used were against AV, LA, LC, SA, and
SM. TLC bioautography, iodine, and UV reaction of TLC fractionated ethyl extract of P.
granatum and C. tora were used against L. Casei and S. mutans. Bioautography, separation
of active principle, and UV fluorescence of ethyl acetate extract of E. cardamomum were
used against L. acidophilus. The bioautographical location of active substances present in
the methanolic extract of Q. infectoria, which is active against S. mutans is shown.
Figure 5.2 shows the bioautographical location of the active substances present in ethyl
acetate extracts of Q. infectoria, which is active against Streptococcus mutans (SM) and
Figure 5.2 Bioautography of ethyl acetate extract of Quercus infectoria against Streptococcus mutans (SM) and
Lactobacillus acidophilus (LA) and TLC of ethyl acetate extract.
94 Natural Oral Care in Dental Therapy
Lactobacillus acidophilus (LA). The result of the present study revealed that ethyl acetate was
found as a highly effective solvent against all the four cariogenic bacteria compared to methanol, hexane, and distilled water. This is due to its extraction capacity. Prabhat et al., 2010
studied four different solvent (acetone, methanol, petroleum ether, and aqueous) extracts
of six medicinal plants, namely, Terminalia chebula, Mimusops elengi, Achyranthes aspera,
Acacia catechu, A. arabica, and Glycyrrhiza glabra [31]. Individual extracts were tested for
their antimicrobial activity against Staphylococcus aureus, S. salivarius, S. sanguis, S. mutans,
Lactobacillus acidophilus, and Candida albicans using the well diffusion method. All the plant
extracts showed significant activity against these pathogens. Among them all, the methanolic extract of T. chebula showed the highest (27 mm) inhibition zone against S. aureus. A
minimum zone (9 mm) of inhibition was recorded when the petroleum ether extract of M.
elengi and A. aspera was evaluated against S. aureus, S. mutans, and Candida albicans.
Nazia Masood, 2008, evaluated the antibacterial activity of aqueous infusions and
decoctions of cumin (Cuminum cyminum L, Umbelliferae), kalonji (Nigella sativa L.,
Ranunculaceae), and poppy seed (Papaver somniferum L., Papaveraceae) against 188
Gram-positive and Gram-Negative bacterial isolates found in the oral cavity of healthy
individuals belonging to 11 different genera [32]. Variable growth inhibition was observed
with the highest percent (73%) from the aqueous decoction of cumin, followed by 51%
in the aqueous decoctions of kalonji, and the very least in the poppy seed (14.4%) in
tested organisms.
We found a promising activity of Q. infectoria in SM, LA, LC, and SA with maximum
efficacy in L. casei (MIC 78 µg/mL). This is five times lesser than what were reported by
Muskhazli et al. (2008) in C. cellulans (500 µg mL−1), which act as bacteriostatic agents
rather than as bactericidal for C. cellulans [33]. In the present study, we could not find the
activity of P. granatum against S. aureus. This is contradictory to the report of Jang et al.
(2009) where they found presence of alkaloids, tannins, and sterols, which was effective
against mithicillin-resistant S. aureus. This could be due to the concentration of the extract;
a higher antibacterial activity would be obtained with a concentrated extract. In this study,
the ethyl acetate extract of E. cardamomum was only active against A. viscosus. This may be
due to the presence of volatile oil because it was reported in the literature.
There is comparatively very meager information on anticariogenic activity of seed
extracts, as majority of reports focus on the antibacterial activity of aerial parts of the leaves,
stem, flowers, roots, and rhizomes extracts. Crude extract of Querecus infectoria was found
to be highly effective against four cariogenic bacteria except A. viscosus. Therefore, the present study may encourage researchers to search the anticariogenic principle found in the
plant seeds. Further chromatographic and spectroscopic analyses of these plant extracts
are necessary for the determination of structures of bioactive compounds responsible for
anticariogenic activity.
5.4 Conclusion
In recent years, plant extracts have shown great potential to purify antimicrobial substances
that are effective against a variety of pathogens, which in turn are used to treat diseases.
Our results on the promising and broad-spectrum anticariogenic activity of ethyl acetate
Anticariogenic Potential of Medicinal Plants 95
and methanolic extracts of Q. infectoria may prove to be useful for clinical evaluation and
development of a suitable formulation for the treatment of dental caries.
Acknowledgments
The authors are thankful to the Director, ARIBAS, and Charutar Vidya Mandal, Vallabh
Vidyanagar for providing the necessary support and research laboratory facilities.
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6
Cytotoxic and Anti-Inflammatory Effect of
Turmeric and Aloe Vera in a Gingivitis Model
Karen Esperanza Almanza-Aranda†, Miguel Aranda-Fonseca,
Gabriela Velazquez-Plascencia and Rene Garcia-Contreras*
*
†
Interdisciplinary Research Laboratory, Nanostructures and Biomaterials Area, National School of
Higher Studies (ENES) Leon Unit, National Autonomous University of Mexico (UNAM),
León, Guanajuato, México
Abstract
The indiscriminate use of synthetic medicines has generated resistance to antimicrobials, and in
response to this, special attention has been placed on medicinal plants. Objective: To know the
cytotoxic and anti-inflammatory effects of turmeric and Aloe vera in human gingivitis-model.
Materials and methods: Human gingival fibroblast (HGF) was subcultured in DMEMsupplemented medium. Turmeric and Aloe vera were inoculated (0–100 mg/mL and 0–25%).
Viable cell number was determined by the MTT method and the mean cytotoxic concentration
(CC50). Interleukin-1β (IL-1β) was used to induce a proinflammatory state. The anti-inflammatory
effect was evaluated by the expression of prostaglandin E2 by an ELISA assay. Data were interpreted with ISO-10993-5 and analyzed with the normality tests of Shapiro–Wilk and Student t
tests with a significance of 0.05. The data were made in triplicate from three independent experiments. Results: The cell viability of turmeric and Aloe vera showed a moderate cytotoxicity
(p < 0.05) with CC50 values of 44.98 ± 1.4 mg/mL and 18.42 ± 2.1%, respectively. The expression
of PGE2 significantly reduced the contact with turmeric and Aloe vera. Conclusions: Turmeric
and Aloe vera have a moderate cytotoxic effect with an anti-inflammatory effect in HGF gingivitis
model. The use of these medicinal plants has a promising potential clinical use for patients with
gingivitis and periodontitis.
Keywords: Medicinal plants, cytotoxicity, anti-inflammatory, Aloe vera, turmeric, gingivitis
6.1 Introduction
A medicinal plant is a natural resource, whose part or extracts are used as a medicinal drug
for the treatment of some condition. Its use dates back to prehistoric times and was one of
the most widespread forms of medicine [1].
*Corresponding author: dentist.garcia@gmail.com
†
Corresponding author: karen_esp13@hotmail.com
Durgesh Nandini Chauhan, Prabhu Raj Singh, Kamal Shah, and Nagendra Singh Chauhan (eds.)
Natural Oral Care in Dental Therapy, (97–110) © 2020 Scrivener Publishing LLC
97
98 Natural Oral Care in Dental Therapy
Gingivitis is the most prevalent inflammatory periodontal disease. Some reports have
estimated that it affects more than 80% of the world’s population [2]. The implicated pathogens in this disease can induce the formation of biofilm around the teeth that initiates the
disease process; the activated host immune inflammatory response leads to pathogenesis;
first, there is gingivitis and then periodontitis. Some of the implicated inflammatory cytokines in this progressive and destructive disease are especially, interleukins (IL) and tumor
necrosis factor-α (TNF-α) that activate the prostanoid mechanisms by the expression of
prostaglandins (PG) and cyclooxygenase. It has been demonstrated that prostaglandin E2
(PGE2) levels in the gingival crevicular fluid are significantly higher in patients exhibiting
gingivitis and periodontitis than those in gingivally and periodontally healthy subjects [3].
In order to solve this disease, the addition of a chemical agent as an adjunct has been suggested to improve the conventional methods of plaque control. It has now been found that
some plants have a preventive and curative effect toward the most common oral conditions.
This has been studied clinically in several groups of people with gingivitis using plants such
as turmeric and aloe vera with different application methods [4].
The use of certain herbs for therapeutic purposes in stomatology has persisted today,
despite the advances recorded in the field of pharmacological or allopathic therapy. There
are references on the use of medicinal plants for oral diseases since pre-Hispanic times
among the Maya. The use of plants to alleviate common ailments at the domestic level is a
knowledge that refuses to disappear; hence, there is a record, either as an alternative or as a
complement to pharmacological therapy in stomatology, of more than 30 plant species [5].
The present chapter summarizes the uses of Aloe vera and turmeric to treat dental
inflammatory diseases highlighting their potential application in dental practice and the
evaluation of cytotoxic and anti-inflammatory effect in a gingivitis model to show evidence
to support these properties in order of the viable cell number and expression of PGE2.
6.2 Gingivitis and Periodontitis
Gingivitis is an inflammatory process limited to the mucosal epithelial tissue surrounding
the cervical portion of the teeth and the alveolar processes. Gingivitis has been classified
by clinical appearance (e.g., ulcerative, hemorrhagic, necrotizing, purulent), etiology (e.g.,
drug-induced, hormonal, nutritional, infectious, plaque-induced), and duration (acute,
chronic). The most common type of gingivitis is a chronic form induced by plaque [6–8].
Periodontitis is one of the most ubiquitous diseases and is characterized by the destruction
of connective tissue and dental bone support following an inflammatory host response secondary to infection by periodontal bacteria. Severe periodontitis, which may result in tooth
loss, is found in 5–20% of most adult populations worldwide [9].
Gingivitis and periodontal diseases comprise a number of infectious and inflammatory
conditions brought about by the interaction between supragingival and subgingival biofilms and the host inflammatory response. The presence of biofilms of the microorganisms
that compose them, and of bacterial metabolites produced following colonization of the
subgingival area, elicits an inflammatory response. Activation of the host immune system,
primarily for protective purposes, ultimately results in tissue destruction by triggering the
synthesis and release of cytokines, proinflammatory mediators, and matrix metalloproteinases. The progression and severity of the periodontal destruction caused by periodontitis
Turmeric and A V for Gingivitis 99
depend on the balance between the virulence of the local biofilm and the host immune
response. A variety of systemic factors and conditions may interfere with and modulate the
relationship between the microbial challenge and the host response. Smoking and diabetes
have classically been recognized as risk factors for periodontitis; smokers and diabetics are
at higher odds of developing periodontitis compared with individuals unaffected by either
condition. Furthermore, longitudinal studies have shown that smokers are at a significantly
higher risk of periodontal attachment loss than are never-smokers [10, 11].
6.3 Aloe Vera
Aloe vera (Figure 6.1a and b) is a native plant from arid regions that has been used as a
medicinal plant for therapeutic reasons since ancient times. Its uses target different pathologies depending on the biological issues like the variety of species of the plant, and even
of cultural issues (traditions and empirical knowledge). There are more than 360 species
of aloe, and there is scientific support for the medicinal properties of only some of them
with aloe vera being the most studied and currently marketed due to the aloe that contains
polyphenol-like and anthracene-like substances that possess beneficial health properties
for different diseases and therapeutic therapies. The beneficial effects on the different diseases are associated with their antioxidant and anti-inflammatory response. These beneficial effects have been observed in several studies both in vivo and in vitro. Although there is
a lot of scientific evidence that support these properties and beneficial effects for aloe, there
are still many aspects to be studied to fully understand the mechanisms of the beneficial
action of Aloe vera [12].
Aloe vera contains 75 potentially active constituents: vitamins, enzymes, minerals, sugars,
lignin, saponins, salicylic acids, and amino acids. Polysaccharides are considered to be the
(a)
(b)
(c)
(d)
Figure 6.1 Aloe vera plant (a–b) and turmeric from which the extract was taken (c–d). Source: Direct.
100 Natural Oral Care in Dental Therapy
active ingredients of Aloe’s anti-inflammation and immune-modulation effects. Inflammation
is a tissue reaction by the body to injury and typically follows burns or other skin insults. It is
classically characterized by swelling, pain, redness, and heat, as well as loss of function [13].
The anti-inflammatory mechanisms of Aloe vera act by inhibiting the synthesis of prostaglandins and reduce the migration and infiltration of leukocytes, the release of histamine,
and the synthesis and secretion of leukotrienes.
6.3.1 Aloe Vera for Gingivitis and Periodontitis
Aloe vera can be very useful to help improve the periodontal health provided that the state
of the denture has been previously checked. It is rather a way to prevent, regenerate, and
eliminate bacteria that affect the gums. The dental uses of Aloe vera are numerous. There is
increased interest among researchers to analyze the use of Aloe vera in dentistry, and various studies have proven the effectiveness of this plant [13].
Some of the effective properties are related to its good antiseptic and anti-inflammatory
properties. They are used in the treatment of gingivitis and periodontitis. They readily
reduce the gingival inflammation and pain associated with it. Clinical studies have shown
that mouthrinses and dentifrices containing Aloe vera have shown a remarkable reduction
in gingivitis and plaque accumulation after its use [14, 15].
Studies by Geetha Bhatt et al. have proven the use of Aloe vera gel as a subgingival
administrator in the treatment of periodontal pockets that reduce the periodontal pathogens and enhance significantly the anti-inflammatory effect. The wound healing and antiinflammatory property of this gel is proven by the reduction in the incidence of alveolar
osteitis in patients who received Aloe vera gel [16].
6.3.2 Aloe Vera: Other Oral Applications
Aloe vera gel incorporated in denitrificans reportedly inhibited the growth of Candida albicans,
Streptococcus viscosus, Streptococcus mutans, and Streptococcus sanguis [17]. Also, the Aloe vera
tooth gel does not contain abrasives, which are present in the normal dentifrices conferring a
good alternative for sensitive teeth. Thus, acemannan, a complex mannose carbohydrate, which
is derived from the Aloe vera plant, has an inherent viscosity, which makes it ideal to be used
as a denture adhesive due to both its adhesive strength and minimal cytotoxicity properties.
On the other hand, its anti-viral properties help in the treatment of herpes simplex and
herpes zoster infections. The sore areas of the oral mucosa which are covered by dentures
can be treated with Aloe gels as they are also a good antifungal agent. They also reduce
the pain associated with ulcers in the commissures of the mouth. Finally, Aloe vera has
demonstrated an antioxidant effect of some of the constituents of the aloe vera gel; three
aloesin derivatives from Aloe, namely, i) isorabaichromone, ii) fer-uoylaloesin, and
iii) p-coumaroylaloesin showed potent free radical and superoxide anion activities [18].
6.4 Turmeric
Turmeric (Figure 6.1c and d) is a product of Curcuma longa, a rhizomatous herbaceous
perennial plant belonging to the ginger family Zingiberaceae, which is native to tropical
South Asia. As many as 133 species of curcuma have been identified worldwide. Most of
Turmeric and A V for Gingivitis 101
them have common local names and are used for various medicinal formulations. India
produces nearly all of the world’s turmeric crop and consumes 80% of it. Turmeric has been
put to use as a foodstuff, cosmetic, and medicine [1, 4]. Turmeric is used as an herbal medicine for rheumatoid arthritis, chronic anterior uveitis, conjunctivitis, skin cancer, smallpox,
chicken pox, wound healing, urinary tract infections, and liver ailments. It is also used for
digestive disorders; to reduce flatus, jaundice, menstrual difficulties, and colic; for abdominal
pain and distension, and for dyspeptic conditions including loss of appetite, postprandial
feelings of fullness, and liver and gallbladder complaints. It has anti-inflammatory, choleretic, antimicrobial, and carminative actions. The main clinical targets of turmeric are the
digestive organs: in the intestine, for the treatment of diseases such as familial adenomatous
polyposis; in the bowels, for the treatment of inflammatory bowel disease; and in the colon,
for the treatment of colon cancer. For arthritis, dosages of 8–60 g of fresh turmeric root
three times daily have been recommended. For dyspepsia, 1.3–3.0 g of turmeric root is recommended [19]. Since turmeric has antimicrobial, antioxidant, astringent, and other useful
properties, it has a potential use in the field of dentistry and many of their specialties.
6.4.1 Turmeric for Gingivitis and Periodontitis
Although chlorhexidine has been regarded as a “gold” standard in dentistry for the prevention of plaque and gingivitis, it has been found that turmeric modulates the cellular action
of several growth factors, cytokines, and transcription factors that could be involved in the
inflammatory process of gingivitis and periodontitis [20–23].
Bhandari and Shankwalker used turmeric in the form of mouthwash and found it to be
an effective anti-inflammatory agent [24]. Also, its usefulness in the dental clinic has been
described as preventive mouthwash of radiation injuries, disinfectant mouthwash, oral
antimicrobial and, above all, a wide approach in relation to cervicofacial cancer. The antiplaque effect of turmeric gel was comparable to chlorhexidine gel. The anti-inflammatory
effect on gingivitis and periodontitis of turmeric gel was similar to those reported in previous studies [25, 26].
The possible mechanism of action of turmeric as an anti-inflammatory agent could be
due to the inhibitory action of inflammatory mediators of arachidonic acid metabolism. It
selectively inhibits the synthesis of PGE2 and thromboxane while not affecting the synthesis of prostacyclin. Turmeric, by virtue of its anti-inflammatory property, reduces inflammatory mediators and causes shrinkage by reducing inflammatory edema and vascular
engorgement of the connective tissue. The mechanisms are related to the incorporation in
collagen, which acts as a supportive matrix for slow release, increases wound reduction, and
enhances cellular proliferation [27, 28].
6.4.2 Turmeric: Other Oral Applications
Turmeric also has analgesic effects acting at the level of the central and peripheral nervous system; its possible mechanisms of action are the inhibition of certain transcription
factors involved in inflammation and the alteration of pain signaling pathways through
ion channels.
It has been found that tinted pit and fissure sealant is useful for applying to tooth surfaces for the prevention or reduction of dental caries. This sealant can be produced from
102 Natural Oral Care in Dental Therapy
a composition comprising a polymerizable resin system containing an acrylic monomer
and at least one colorant selected from the group consisting of Annatto extract, turmeric
extract, and β-Apo-8 -Carotenal. Accordingly, dental plaques are generally stained with
dental-plaque staining agents, which contain dyes, to reveal their locations in order to
uncover the attached dental plaques. The dental-plaque detection system includes a dentalplaque staining agent, which contains at least one selected from the yellow pigment of benikoji, turmeric extracts, and curcumin; and a light-emitting apparatus, which outputs light
having a wavelength within the range of 250 to 500 nm to an object in the oral cavity where
the dental-plaque staining agent is attached. The yellow pigments of beni-koji and turmeric
are known as staining agents and are also used for other purposes [29].
6.5 Methodology
6.5.1 Materials and Methods
6.5.1.1 Authorization
To obtain human gingival fibroblasts (HGF), gingival tissue was collected without pathological damage from healthy patients, who underwent third molar surgical odontectomy
at the National School of Higher Studies (ENES) Leon Unit of the National Autonomous
University of Mexico (UNAM). To this end, this protocol was submitted to the Bioethics and
Biosafety Committee of the ENES León Unit of the UNAM, where the patients gave their
authorization so that their extracted tissues could be used in this investigation. Samples
were stored immediately after extraction in Falcon tubes with 10 ml of phosphate buffer
saline (PBS, pH 7.4) and 1% antibiotic (Gibco , Grand Island, NY, EU).
6.5.1.2 Cell Culture
Once in the laboratory, the gingival tissue was washed twice with PBS. The HGF was obtained
inside the laminar flow bench (Lumistell , Celaya Gto, Mexico). Explants, approximately
1 × 1 mm, were made with a No. 20 scalpel blade on a sterile glass slide and were inoculated
in 10-cm-well sterile culture dishes (Thermo Fisher Scientific, Rochester, NY, USA), then
10 mL of DMEM culture medium supplemented with 20% sterile fetal bovine serum (FBS,
Gibco ), 1% of antibiotic (10,000 IU/mL penicillin G and 10,000 mg/mL streptomycin,
Gibco ), and 1% Glutamax (Gibco ) were subsequently allowed to incubate at 37°C with
5% CO2 and 95% humidity, for 3 weeks until a cellular monolayer of 80% of its cellular proliferation was obtained in an incubator (Binder, Tuttlingen, Germany). The culture medium
was changed every third day after week 1.
6.5.1.3 Cell Subculture
The cells were washed three times with phosphate buffer solution (PBS, 5 ml), 1 ml of 0.05%
trypsin (Gibco ) EDTA-2Na was added and incubated for 5 min at 37°. The cell count
was carried out with the cell count method where a Neubauer chamber (BOECO 1/10
mm, Germany) and automated cell counter (Bio-Rad 2000 TC10, Hercules, California,
Turmeric and A V for Gingivitis 103
USA) were used by exclusion of blue from trypan (Trypan Blue Dye 0.40%, Bio-Rad,
Hercules California: EU). The number of cells per milliliter of suspension allowed calculating the total number of cells. Cells were subcultured in the range of 5 × 105 cells/mL
for each experiment.
6.5.1.4 Cytotoxicity Test
The first experiment was performed where 96-well dishes were used in the HGF and left
to incubate for 48 h at 37°C with 5% CO2 and 95% humidity. Turmeric (Figure 6.2d–f)
and Aloe vera (Figure 6.2a–c) were inoculated at 0–100 mg/mL and 0–25%, respectively.
They were allowed to incubate for 24 h at 37°C with 5% CO2 and 95% humidity. The viable cell number and the mean cytotoxic concentration (CC50) were calculated from the
dose–response curve. Briefly, the culture medium was removed and replaced with the MTT
reagent (Thiazolyl Blue Tetrazolium Bromide, Sigma Aldrich) at a concentration of 0.2 mg/
mL in DMEM for 7 h at 37°C with 5% CO2 and 95% humidity. The formazan crystals were
dissolved with dimethyl sulfoxide (DMSO, J.T Baker). The plates were analyzed in microplate spectrophotometer (Thermo Scientific Multiskan GO, Rochester, NY, USA) at 570 nm.
6.5.1.5 Anti-Inflammatory Activity in a Gingivitis Model
HGF cells were subcultured at the aforementioned density in 24-well dishes. Interleukin
1-beta (IL-1β, recombinant human; >97% Purity; Minneapolis, MN, USA) was reconstituted with Bovine Albumin (IMMUCOR GAMMA, Norcross , GA, USA). The IL-1β (3 ng/
mL) was inoculated in the plates to induce a pro-inflammatory state for 3 h and to function
as a positive control. Turmeric and Aloe vera were inoculated at three concentrations, 0,
12.5, 25 mg/mL and 0%, 12.5%, 25%, and incubated for 24 h. The supernatant of the culture medium was stored in Eppendorf tubes, and PGE2 expression was performed with an
(a)
(b)
(c)
(d)
(e)
(f)
Figure 6.2 Cell culture in contact to Aloe Vera and Turmeric: Aloe Vera: (a) Control group; (b) 0.8%
concentration; (c) 2.5% concentration. Turmeric: (d) Control group; (e) 3.125 mg/mL concentration;
(f) 100 mg/mL concentration. Source: Direct.
104 Natural Oral Care in Dental Therapy
expression kit (R&D Systems, Minneapolis, USA) with ELISA according to the manufacturer’s instructions.
6.5.1.6 Statistical Analysis
Each reported value represents the mean ± standard deviation (S.D.). The data were subject to Shapiro–Wilks normality test and paired t-test using Statistical Package for Social
Science (Chicago, IL, USA). Differences were considered significant at p < 0.05 with an
interval confidence of 95%. The experiments were carried out for triplicate from three
different experiments resulting in n = 9 samples per group. The viable cell number from
dose-response and CC50 values were interpreted based on ISO-10993-5: Tests for in vitro
cytotoxicity of medical devices.
6.5.2 Results
6.5.2.1 Cytotoxicity
Turmeric and Aloe vera exhibited essentially moderate cytotoxicity in a dose-dependent
manner (p < 0.05) against HGFs cell over the concentration range from 0.098 to 100 mg/
140
120
100
Viable Cell Number (%)
Viable Cell Number (%)
120
80
60
40
20
(a)
100
80
60
40
20
(c)
25
3
.5
12
1
6.
6
3.
8
1.
4
0.
0.
1
2
0.
9
0.
04
0.
0
0.
mg/mL
%
20
25
18
16
IL-1β (+)
15
IL-1β (–)
10
5
(b)
PGE2 (ng/mL)
20
PGE2 (ng/mL)
4
02
0
50
10
.5
25
12
5
25
6.
3
12
56
3.
1.
1
1
78
0.
5
39
0.
19
0.
0.
09
0
8
0
14
12
10
8
6
4
2
0
0
0
12.5
mg/mL
25
IL-1β (+)
IL-1β (–)
(d)
0
12.5
%
25
Figure 6.3 Viable cell number and anti-inflammatory effect of turmeric and aloe vera in culture with
human gingival fibroblast (HGF) cells and gingivitis-model. Near-confluent HGF cells were incubated
for 48 h with 0–100 mg/mL (a) or 0–50% (c), respectively. The viable cell number was then determined
by the 3-(4,5-dimethylthiazol-2yl)-2,5-diphenyltetrazolium bromide assay (A). Synergistic stimulation of
prostaglandin E2 (PGE2) production by turmeric (b) or aloe vera (d) interleukin-1β (IL-1β, 3 ng/mL). The
concentration of PGE2 in the culture medium was determined by ELISA, according to the manufacturer’s
instruction (B). Each value represents the mean ± S.D. of three independent experiments (each experiment
was performed in triplicate). *p < 0.05, **p < 0.01 paired t-test. Source: Direct.
Turmeric and A V for Gingivitis 105
mL and 0.024–25% with CC50 values of 44.98 ± 1.4 mg/mL (Figure 6.3a) and 18.42 ± 2.1%
(Figure 6.3c), respectively.
6.5.2.2 Anti-Inflammatory Activity in a Gingivitis Model
Regardless of the presence or absence of IL-1β (3 ng/ml), it significantly (p < 0.05) stimulated the production of PGE2 in HGF gingivitis model. Synergically, IL-1β and turmeric
or aloe vera reduced significantly (p < 0.01) (Figure 6.3b and d) the PGE2 production and
showed the anti-inflammatory effect of both samples.
6.5.3 Discussion
Dentobacterial plaque is the main causative agent of periodontal disease. Oral hygiene and
the elimination of this plaque are of the utmost importance in the prevention of periodontal
disease. Adulthood, style and quality of life, and some psychomotor disability are the risk
factors involved in proper oral and personal hygiene, which has stimulated the search for
added chemotherapeutic agents to mouthwashes to improve plaque control dentobacteriana and prevent both gingival and periodontal diseases. Therefore, various studies have
been suggested to reduce the bacterial load in the host. Herbal products are agents that
have been widely used from our origin to reduce bacterial population. Different researches
have studied these purposes, and their results showed very satisfactory conclusions. This
allowed us to evaluate the efficacy of turmeric and aloe vera in oral health.
6.5.3.1 Cytotoxicity
Some studies have reported the non-cytotoxic effect of Aloe vera in culture with Vero cells
at concentrations from 0 to 5% compared with the untreated healthy cells. Based on the
results, up to 5% of the gel extract was nontoxic for Vero cells. Here our results suggest that
18.4% reduce the 50% of the viable cell number in contact with HGF for 24 h with any side
effect at 5% concentration of Aloe vera [30].
International toxicological studies establish an LD50 of 30 mg/kg of the aqueous extract
of turmeric and warn that the continuous consumption of turmeric orally, in doses of 100
mg/kg (higher than those indicated in the indications and above the LD50 levels), has
an ulcerogenic effect [31]. Similarly, a study conducted at the Center of Toxicology and
Biomedicine of Santiago de Cuba, found no level of toxicity when evaluating the acute oral
toxicity of Curcuma longa [32].
An in vivo study with rodents confirmed that turmeric modulates the formation of
adducts (DNA and proteins) of aflatoxin B1, AFB, in addition to improving the activity of
the enzymes GSHT and UGT1A1, which significantly reduced the activity of the enzyme
CYP1A1. At the molecular level, turmeric decreased the urinary excretion of the AFB-Nguanine adduct, hepatic DNA, and serum albumin adduct. This is of great importance to
counteract the toxicity of aflatoxin B1, through the consumption of turmeric in the diet of
people exposed to this toxin [33]. Our results showed that turmeric possesses moderate
cytotoxicity and is well tolerated by the human gingival fibroblast, comparable to the results
mentioned above.
106 Natural Oral Care in Dental Therapy
Another in vitro study evaluated the effect of Aloe vera associated with endodontic medication, with or without irradiation with laser photobiomodulation (FTL) in human pulp
fibroblasts and concluded that Aloe vera allowed greater cell viability in human pulp fibroblasts in the presence of calcium hydroxide [34]. In our research, we can verify that at
medium concentration, there is greater cell viability and proliferation, and at high concentration, there is a moderate level of cytotoxicity depending on the doses. Cell viability
was decreased with both plants in high concentrations, probably because they modulate
mechanisms related to cell proliferation, survival routes, caspase activation pathways, and
tyrosine kinase activity.
6.5.3.2 Anti-Inflammatory Activity
The anti-inflammatory property of turmeric has been studied and has shown a significant reduction in inflammation. Bhandari and Shankwalker used turmeric in the form
of mouthwash and discovered that it was an effective anti-inflammatory agent. For the
main ingredients of this formulation, each gram contains 10 mg of Curcuma longa extract
together with erythrosine and titanium dioxide [35, 36]. Similarly, our results showed
that 12.5 mg/mL reduced the expression of PGE2 with previous pro-inflammatory stimulation with IL-1β (3 ng/mL) and showed an effective anti-inflammatory effect in a
dose-dependent manner. Mulikar S et al. and Waghmare PF et al. studied the efficacy of
curcumin mouthwash as a complement to scaling and root planning in the treatment of
chronic gingivitis and to compare chlorhexidine in terms of its anti-inflammatory and
antimicrobial properties. They concluded that curcumin is comparable to chlorhexidine
as an anti-inflammatory mouth rinse and is an effective adjunct to periodontal therapy [37, 38].
Bathini et al. and Gottumukkala et al. studied the effectiveness of subgingival irrigation of a 0.1% indigenous curcumin solution in patients with clinical and microbiological
parameters: a randomized pilot clinical trial [39].
In the case of Aloe vera, a research group carried out a randomized, double-blind clinical
study to evaluate the antiplaque and antigingivitis efficacy of the mouthwash [40].
In our study, the data analyzed showed that turmeric is a medicinal plant with a property that reduces inflammation. This can be attributed to its ability to inhibit both the
biosynthesis of inflammatory prostaglandins of arachidonic acid and the function of neutrophils during inflammatory states. Aloe vera is a plant with anti-inflammatory activity:
it inhibits the synthesis of prostaglandins and reduces the migration and infiltration of
leukocytes, the release of histamine, and the synthesis and secretion of leukotrienes. Our
results showed the potential anti-inflammatory effect of both turmeric and Aloe vera in
a gingivitis model by reducing dose-dependently the expression of PGE2 in culture with
HGF.
On the other hand, future experiments should be focused on the evaluation of Aloe
vera action against microorganisms such as Aggregatibacter actinomycetemcomitans,
Porphyromonas gingivalis, and Bacteroides fragilis by agar diffusion or microdilution as well
as co-culture with HGF or human periodontal ligament fibroblast (HPLF) to a more realistic gingivitis or periodontitis model. The antibacterial effect as well as the beneficial effects
of aloe vera in mouthwashes intended to reduce dentobacterial plaque and prevented gingivitis [41].
Turmeric and A V for Gingivitis 107
6.6 Perspectives for the Future
The use of medicinal plants in dentistry are increasing lately because they have good properties, low economic cost and are quite accessible, and are a good alternative to reduce the
demand for synthetic medications, which have important side effects such as cytotoxicity
and teratogenicity. Interest is increasing in the use of Aloe vera and turmeric in dentistry,
and this natural therapy has already proven its unlimited use in the field.
More and more studies are carried out where they demonstrate the efficacy of their
anti-inflammatory properties and how they can be applied for the benefit of the population,
which is why these plants represent a promise for the future of dentistry. However, most of
these studies are short term. More long-term studies are needed and with more population
samples to determine how these plants act in oral health.
6.7 Conclusions
The effect of turmeric and Aloe vera in culture with HGF showed moderate cytotoxicity
with an anti-inflammatory effect in a human gingivitis model. The use of these medicinal
plants has a promising potential clinical use for patients with gingivitis and periodontitis.
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7
Effects of Bauhinia forficata Link in Reducing
Streptococcus mutans Biofilm on Teeth
Julio Cesar C. Ferreira-Filho1, Mariana Leonel Martins1,
Andressa Temperini de Oliveira Marre2, Juliana Soares de Sá Almeida2,
Leandro de Araújo Lobo2, Adriano Gomes Cruz3, Marlon Máximo de Andrade3,
Thiago Isidro Vieira1, Maria Teresa Villela Romanos4, Lucianne Cople Maia1,
Ana Maria Gondim Valença5 and Andréa Fonseca-Gonçalves1*
1
Department of Pediatric Dentistry and Orthodontics, School of Dentistry, Universidade Federal do
Rio de Janeiro (UFRJ), Rio de Janeiro, RJ, Brazil
2
Department of Medical Microbiology, Instituto de Microbiologia Professor Paulo de Góes,
Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ, Brazil
3
Department of Foods, Instituto Federal de Educação, Ciência e Tecnologia do Rio de Janeiro (IFRJ),
Rio de Janeiro, Brazil
4
Department of Virology, Instituto de Microbiologia Professor Paulo de Góes, Universidade Federal do
Rio de Janeiro, Rio de Janeiro, RJ, Brazil
5
Department of Clinic and Social Dentistry, School of Dentistry, Universidade Federal da Paraíba
(UFPB), João Pessoa, PB, Brazil
Abstract
Bauhinia forficata Link has been described as having bioactive properties including antimicrobial
activity. However, this natural product has not yet been tested against dental biofilm. This book
chapter evaluated by means of a laboratory study the effects of a tincture made from Bauhinia forficata Link leaves (TBF) on Streptococcus mutans biofilm formed on teeth. Susceptibility tests were
performed to observe the viability of S. mutans. Total solids (ºBrix), pH, mineral content, and cytotoxic potential of the TBF on oral fibroblasts were determined. S. mutans biofilm was cultivated on
enamel tooth blocks (n = 48) in polystyrene plates. After biofilm formation (24 h, 37°C), the blocks
were treated (50 µL/1 min for 3 days) with 0.12% chlorhexidine; 0.11% TBF, 0.388% ethanol, 0.233%
TBF, and 0.816% ethanol. The treatments were compared by means of analysis of variance/Tukey’s
test. The TBF was found to contain calcium, phosphorus, and magnesium among other elements and
promoted an S. mutans optical reduction when compared with the control (p < 0.05). The TBF thus
constitutes a promising adjuvant substance for the prevention of carious lesion due to its ability to
reduce S. mutans biofilm on teeth. For this reason, this chapter aims to present a discussion of the
oral antibiofilm effect of TBF.
Keywords: Microbiology, dental plaque, hydrogen-ion concentration, tooth, phytotherapy
*Corresponding author: andrea.goncalves@odonto.ufrj.com
Durgesh Nandini Chauhan, Prabhu Raj Singh, Kamal Shah, and Nagendra Singh Chauhan (eds.)
Natural Oral Care in Dental Therapy, (111–120) © 2020 Scrivener Publishing LLC
111
112 Natural Oral Care in Dental Therapy
7.1 Introduction
Numerous microorganisms in the oral cavity are able to trigger dental caries [1].
Streptococcus mutans, a Gram-positive anaerobic bacterium, contributes to biofilm formation and build-up, and it is the major microorganism involved in caries process [2].
Its relevance is to be attributed to its acidogenic and aciduric properties, which facilitates
the survival, growth, and maintenance of its metabolism under acidic environments [3].
Wherefore, S. mutans biofilms have been largely studied in vitro due to difficulties in developing in vivo researches for controlled cariogenic conditions [3].
The use of medicinal plants as another treatment choice for oral diseases has received
great scientific attention [4], particularly for the reason that they do not origin bacterial
resistance, as may happen with antibiotics [4, 5]. Several studies have investigated the inhibitory properties of natural products versus the growth of oral microorganisms [6–9]; such
plants may represent a positive strategy for caries control [8].
Bauhinia forficata Link (Family Leguminosae, Subfamily Caesalpinioideae) has been
described as having outstanding bioactive properties including antioxidant activity [10],
antimutagenic action [11], antilipidemic, hypocholesterolemic [12], and antimicrobial
activity [11, 13]. This plant grows as a heliophilous medium-sized tree (5–9 m high), indifferent to soil moisture conditions, and possessing bilobed and elongated leaves [14]. The
antimicrobial activity of B. forficata L. has already been reported against planktonic cells
[11, 13]. The antimicrobial effects of its leaves, however, which are extensively used as an
antidiabetic herbal medicine [15], have not yet been tested against dental biofilm. Thus, the
objective of this book chapter was to present a discussion, by means of an in vitro study, of
the anti-S. mutans biofilm effect of a tincture made from leaves of B. forficata L. (TBF). The
hypothesis is that the extract of TBF reduces the S. mutans biofilm formed on teeth.
7.2 Materials and Methods
7.2.1 Recognition, Production, and Chemical Characterization of Ethanolic
Tincture From B. forficata L. Leaves
This plant was collected in the city of Ribeirão Preto, Brazil (21°07 S, 47°45 W, 523,874 m altitude). The leaves were identified, indexed, and stored in the Herbarium of the Universidade
Federal do Rio de Janeiro in Rio de Janeiro, Brazil, with the registration number 40781. The
TBF was made by the percolation method, using 20 g of the plant in 100 g of the tincture.
Ethanol 70% was used as the solvent.
The measurement of total soluble solids was performed by means of a digital refractometer (PAL-1; Atago Co., Ltd., Minato-ku, Japan) in which values were expressed as °Brix. The
pH was evaluated with a pH meter (DM20 Digitalized; Digimed, Santo Amparo, SP, Brazil).
Both investigations were done in triplicate, and the final results were showed as the average
of the values.
To quantify the mineral content, aliquots (3 mL) of the TBF at 20% were sampled
and centrifuged (3,000 g, 3 min, 48°C). To the supernatant was added 250 mL of 65%
nitric acid. The sample was then evaluated by atomic absorption spectroscopy (Aanalyst
300; PerkinElmer, Inc., Waltham, MA, USA) to quantify the content of sodium (Na),
Oral Antibiofilm Effect of Bauhinia 113
potassium (K), magnesium (Mg), calcium (Ca), zinc (Zn), and phosphorus (P). All analyses
were performed in quadruplicate.
7.2.2 Microbial Strains and Preparation of Inoculum
Samples of S. mutans [American Type Culture Collection (ATCC) no. 25175] were used to
form the inoculum. Colonies of the pure strain were selected; moved to phosphate-buffered
saline; and was standardized at an absorbance of 0.15 at 520 nm (Libra S2 Colorimeter;
Biochrom, Cambridge, UK), equivalent to approximately 108 colonies of the microorganisms [colony-forming units (CFU)/mL].
7.2.3 Minimum Inhibitory Concentration (MIC) and Minimum Bactericidal
Concentration (MBC)
The minimum inhibitory and bactericidal concentrations (MIC and MBC, respectively)
were evaluated using the Clinical and Laboratory Standards Institute M100-S22 specifications [16] with a modification [7]. Microplates (96 wells) were inoculated (5 × 105 CFU/
mL of each strain) with 100 µL of brain heart infusion medium (BHI; Difco, Sparks, USA).
The tested TBF concentrations ranged from 95.238 to 0.0272 mg/mL (9.5238–0.00272%)
against S. mutans. Chlorhexidine digluconate at 0.12% (0.12% CHX) was the positive control, and ethanol (70%) was also tested (from 33.333% to 0.009516%), as it was the main
tincture solvent. The MIC was considered as the lowest concentration of solution that did
not exhibit turbidity in the culture medium, as confirmed by resazurin salt (Sigma-Aldrich,
St. Louis, MO, USA). The MBC corresponds to the minimum concentration that did not
show microorganism growth after subculturing 50 µL of concentrations higher than the
MIC on the BHI agar.
7.2.4 Kill-Kinetic Assay
The kill-kinetics were demonstrated by the growth curve of the tested microorganism
(S. mutans ATCC no. 25175), based on the recommendations of the CLSI M100-S25 guide
for broth microdilution, with anaerobe and aerobe antimicrobial susceptibility [17]. It was
used to measure the effects of the TBF on bacterial growth. Initially, the BHI medium containing the 0.11% TBF (1.110 mg/mL) and 0.388% ethanol (3.88 mg/mL) was added, in
triplicate, to the wells of a 96-well plate. For the inoculum, microorganisms were initially
grown in that medium for 24 h, then inoculated into the fresh medium and allowed to grow
to McFarland 0.5. The cultures were diluted (1:15) in the same medium, and an inoculum
of 20 μL was inserted to each well, corresponding approximately 106 CFU/mL. Positive
controls for microorganism growth were made in the medium without TBF, or with the
excipient (ethanol) alone. Negative controls without the inoculum were used as a reference.
The 96-well plates remained at 37°C under microaerophilic conditions for S. mutans. Cell
growth was measured in arbitrary units, in relation to the optical density of the medium at
620 nm. Readings were taken every 60 min, using an Infinite F50 plate reader (Absorbance
microplate reader F50 ; Tecan, Männedorf, Switzerland) over 48 h. Growth curves were
plotted using the average readings of duplicates over time from a representative test. The
experiment was performed in triplicate.
114 Natural Oral Care in Dental Therapy
7.2.5 Cytotoxic Potential
The cytotoxic level of the TBF was investigated by the “dye uptake” technique [18].
Monolayers of confluent fibroblast cells L-929 (ATCC CCL-1) on polystyrene 96-well
microplates were tested against alcohol and TBF solutions, using the following concentrations: 1.11 mg/mL (0.11%) and 2.33 mg/mL (0.233%). Eagle’s Minimum Essential Medium
(Cultilab, Campinas, Brazil) was used as the diluent (cell maintenance medium), and the
plates remained at 37°C during 15, 30, and 60 min in microaerophilic environment.
The cell viability reading was performed with a spectrophotometer (model Elx800; BioTek Instruments, Winooski, VT, USA), using a wavelength of 492 nm. Viable cell percentages for each tested solution were found by means of optical density values. White cell
control (wells with untreated L-929 cells), 0.12% CHX, and a positive control (1% Tween)
were also analyzed. The cytotoxic potential was calculated based on the value of cell viability of the negative control (100%).
7.2.6 Tooth Selection and Preparation for Microbiologic Assay Using
an S. mutans Biofilm
Bovine incisors (n = 48) stored in 2% formaldehyde without caries, spots, cracks, or other
defects in the enamel were selected. Cuts were made, using a water-cooled diamond saw
(Bühler, Uzwill, Switzerland) to acquire blocks (4 × 4 × 2 mm). These enamel surfaces were
polished, using 600- and 1,200-grit silicon carbide papers (Extec Corp., Enfield, CT, USA),
followed by a 1-mm diamond abrasive slurry (Extec Corp., Enfield, CT, USA), and then
were ultrasonically washed with distilled and deionized water (Merck Millipore, Darmstadt,
Germany). Finally, the quality of the polished surfaces of the enamel was verified by means
of an optical microscope with 50× magnification.
Forty-eight bovine enamel blocks, with a surface microhardness mean of 312.73 ± 6.85
KHN, were randomly positioned in single wells in 24-well polystyrene plates (n = 2). These
were then sterilized with ethylene oxide (Bioxxi Esterilização, Rio de Janeiro, Brazil). Next,
added to each well was 1,492.5 µL of BHI broth with 2% sucrose (Oxoid Ltd., Basingstoke,
UK) plus bacterial inoculum (7.5 µL of S. mutans), with a final concentration of 5 × 105
CFU/mL. Then, the system was incubated under microaerophilic conditions, for 24 h, so
that biofilm formed on the enamel blocks (Figure 7.1).
After biofilm growth, the blocks received the following treatment (G, n = 7): 0.12%
chlorhexidine (G1), 0.11% TBF (G2), 0.388% ethanol (G3), 0.233% TBF (G4), and 0.889%
ethanol (G5). Other two groups were separated out—a growth control (BHI medium with
inoculum; G5) group and a block removed for S. mutans count after 24 h (G7) group,
respectively—to register baseline values. Six other blocks, with BHI medium without inoculum, represented the sterilized control or blank control.
Treatment was carried out after the culture medium removal from the wells with a
pipette. The enamel blocks were treated with 50 μL of the test substance, which remained
for 1 min on these fragments. After this period, the blocks/biofilms were washed twice with
1,000 μL of sterile deionized water. After washing, the culture medium was renewed (BHI
supplemented with 2% sucrose, but without the inoculum). The plate/block/biofilm system
was transferred to a microbiological oven, under 5% CO2, for 24 h, and the treatment was
repeated at the same time in 3 days.
Oral Antibiofilm Effect of Bauhinia 115
20kV
X200 100 µm
COPPE
20kV
X200 100 µm
COPPE
Figure 7.1 Scanning electron microscopy pictures of two enamel samples: the left one is from G7- after 24-h
biofilm formation (baseline control) and the right one is from the blank control (photomicrographs with
magnification of 500×).
At the end of the assay, the tooth blocks were removed from the plate and transferred to
microtubes with 1 mL of saline solution. This block was vortexed (1 min) to separate the
biofilm. From the suspension, 100 μL was seeded (dilutions of 10−1 to 10−7), in duplicate,
spread over Petri dishes with BHI agar for S. mutans counts. The dishes were moved to a
microbiological stove for 48 h under 5% CO2, and the results were shown in Log10 CFU/mL.
7.2.7 Statistical Analysis
The Statistical Package for the Social Sciences version 21.0 software program (IBM Corp.,
Armonk, NY, USA) and Graph Pad PRISM 6.0 (Graph Pad Inc., San Diego, CA, USA)
were used in the data analyses. For the microbiological assays, cytotoxic potential, and killkinetics, the normality was verified by Shapiro–Wilk test (CFU counts, % cell death, and
optical density). One-way analysis of variance, followed by the Tukey post hoc test, was used
to compare the means according to the treatment groups. For all analyses, a significance
level of 5% was considered.
7.3 Results and Discussion
The pH of the TBF was 5.8 ± 0.1, and the total solid content was 17 ± 0.0 °Brix. Considering
the elemental content, high proportions of calcium (1,369.65 ± 22.54 mg/kg) and phosphorus (1,067.39 ± 9.51 mg/kg) were observed in the TBF. Also, the presence of magnesium
(111.87 ± 3.53 mg/kg), a natural antimicrobial, was recorded (Table 7.1).
The TBF showed bacteriostatic (MIC: 0.11%) and bactericidal (MBC: 0.11%) activity
against S. mutans. Moreover, the tincture (0.233%) showed acceptable values of % cell
death, even after 60 min of contact (Table 7.2). Actually, the TBF in all tested concentrations
was significantly different from that in the positive control group (p < 0.00) over all analyzed periods. The 0.12% chlorhexidine promoted a considerable percentage of cell death
(55.06–69.9%), with a reduction of the viable cells after 60 min (p < 0.05), and preserved
fewer oral fibroblast cells, at all time-points, then the TBF in both concentrations (p < 0.01).
116 Natural Oral Care in Dental Therapy
Table 7.1 Mineral contents of TBF at 20%.
Minerals (mg/kg)
TBF (mean ± SD)
Sodium (Na)
663.43 ± 9.26
Potassium (K)
921.00 ± 16.19
Magnesium (Mg)
111.87 ± 3.53
Calcium (Ca)
1369.65 ± 22.54
Zinc (Zn)
2.73 ± 0.26
Phosphorus (P)
1067.39 ± 9.51
Note: SD—Standard deviation.
Table 7.2 Potential cytotoxic in four time points (0, 15, 30, and 60 min) by percentage count of cell
deaths after treatment with TBF, in different concentrations, and controls.
% Cell death (± SD)
Substances
T0
T15
T30
T60
0.11% TBF
18.59 (2.26)a,A
12.99 (8.42)a,AB
9.39 (2.85)a,B
4.32 (3.13)a,C
0.388% Ethanol
8.36 (2.05)b,A
22.49 (6.99)a,B
15.58 (1.97)a,BC
10.96 (8.96)a,AC
0.233% TBF
26.93 (3.96)c,A
17.78 (5.91)a,AB
13.71 (4.34)a,B
14.47 (9.09)a,B
0.816% Ethanol
9.13 (3.34)b,A
20.08 (6.23)a,B
15.78 (7.91)a,ABC
7.55 (7.21)a.AC
0.12% CHX
69.90 (1.87)d,A
69.35 (2.87)b,A
69.43 (0.34)b,A
55.06 (5.73)b,B
1% Tween
81.45 (0.99)e,A
79.92 (0.85)b,A
83.81 (0.49)c,A
80.01 (1.05)c,A
Note: Distinct lowercase letters show difference of % cell death at the same time, considering the columns.
Distinct capital letters show difference of % cell death between times, considering the same rows.
The alcohol in both concentrations promoted cell death less than 25% for all evaluated
times (Table 7.2).
In view of the relative increase in the number of microorganisms resistant to antiseptics
and conventional antibiotics, there is a rising interest in the use of tests to investigate antimicrobials of natural origin [19]. Therefore, studies that address the use of natural plants are
perfectly reasonable, mainly those where a biofilm/caries model is controlled by an in vitro
environment, since they simulate a real condition [6, 20]. The present research investigated the
antibacterial action of B. forficata L. against an S. mutans biofilm formed on dental surfaces.
The TBF, at the highest concentration tested, expressed antibacterial activity against
S. mutans biofilm, similar to chlorhexidine at 0.12% (p > 0.05). This is a promising result,
since there are no reports, to our knowledge, of adverse effects concerning the topical
use of TBF consumption. On the other hand, prolonged use of chlorhexidine may trigger a decrease in gustatory sensitivity, dental pigmentation, and bacterial resistance [21].
Separately, we highlight that the concentration of TBF tested in the assay was lower than
Oral Antibiofilm Effect of Bauhinia 117
those previously reported as toxic [11, 13, 22]. This was confirmed by the high viability of
oral fibroblasts after contact with TBF at all exposure times. Thus, TBF probably does not
present any risk to human health.
Laboratory studies suggest that the leaves of B. forficata L. are rich in polyphenols [10, 13,
23, 24]. Polyphenols have multiple mechanisms of antibacterial activity, including the suppression of the quorum sensing, or other bacterial global regulator systems. Another point
that should be highlighted is the presence of Mg in the TBF; Mg has attracted interest as
an antibacterial biomaterial [25], owing to its ability to alkalize the surrounding medium
during degradation [26]. Therefore, it is plausible to associate the presence of polyphenols
and Mg in the chemical constitution of the leaves of B. forficata L. as the possible source of
the antimicrobial action found in this study against S. mutans biofilm.
Although the polyphenol composition of B. forficata L. has already been disclosed, further studies using chromatographic analyses, in order to identify and quantify the phenolic content of the presented solution, are needed. Even with this limitation, however, the
originality of the present work should be emphasized, since it is the pioneer study in the
evaluation of the antibacterial effect of B. forficate L. on the dental biofilm.
Considering the results of the growth curve, the TBF acted differently on S. mutans in comparison with the control (Figure 7.2); specifically, the TBF demonstrated an optical density
reduction (0.32 nm) in the development of S. mutans after 48 h of treatment (p < 0.01).
Considering the inhibitory properties of the TBF against S. mutans demonstrated in the
growth curve over time, the authors observed lower bacterial levels, mainly after the first
18 h (p < 0.05), compared with those in the culture medium alone and ethanol. Thus, we
suggest that the TBF presents considerable substantivity and a low degree of degradation
over time. Further studies should be performed to confirm such a hypothesis, however.
The biofilm assay on the dental enamel surface showed that the baseline group (G7) presented the largest counts of viable microorganisms (6.89 ± 0.19 Log10 CFU/mL; p < 0.01).
The treatment with 0.233% TBF (G4: 4.51 ± 0.65 Log10 CFU/mL) was effective in reducing
the biofilm compared with other groups (p < 0.01), except for G1 (4.62 ± 0.37 Log10 CFU/
mL; p = 0.996). G3 (5.76 ± 0.21 Log10 CFU/mL) and G5 (6.03 ± 0.2 Log10 CFU/mL) presented the same behavior (p = 0.856 and 0.98, respectively) as that of G6 (6.04 ± 0.32 Log10
CFU/mL), while G2 (0.11% TBF) presented better activity in reducing biofilm versus G3,
G5, G7, and G8 (p < 0.01) (Table 7.3).
Streptococcus mutans
OD 600nm
0.6
0.5
0.4
0.3
0.2
0.1
0.0
0
5
10
15
20
25
30
Hours
35
40
45
50
Figure 7.2 Streptococcus mutans kill-kinetics of TBF and control for 48 h. The S. mutans optical density was
evaluated at 60-min intervals after contact with ethanol (blue line) and TBF (green line). Bacterial growth was
also verified (black line).
118 Natural Oral Care in Dental Therapy
Table 7.3 S. mutans count (Log10 CFU/mL) of mature
biofilm formed on enamel bovine blocks according to each
studied group (G).
Group
Log10
Mean (± SD)
G1
4.62 (0.37)a
G2
5.23 (0.77)b
G3
5.76 (0.21)bcd
G4
4.51 (0.65)a
G5
6.03 (0.20)de
G6
6.04 (0.32)e
G7
6.89 (0.19)f
Note: Distinct letters show statistical difference in Log10 CFU
counts between the groups. G1: 0.12% CHX, G2: TBF at the
MBC concentration, G3: ethanol at the MBC concentration, G4:
TBF at the MBC × 2 concentration, G5: ethanol at a MBC × 2
concentration, G6: growth control (BHI medium with inoculum),
G7: S. mutans count after 24 h (baseline).
The S. mutans is the principal bacteria of the mutans streptococci group that is involved
with the initial development and severity of caries lesions [2, 27, 28]. Thus, in the present book chapter, S. mutans was chosen as the microbial parameter for the in vitro study.
Moreover, the most concentrated TBF was chosen as a treatment option because isolated
planktonic cells were found to be more vulnerable to treatment with antibacterial than a
structured biofilm. Therefore, the authors also elected for a higher, nontoxic concentration
of TBF for the biofilm assay.
7.4 Final Considerations
The TBF has a pH value above that for enamel dissolution, contains Mg, has a low cytotoxic
potential in oral fibroblasts, shows inhibitory activity against S. mutans, and appears to be
an efficient adjuvant in the prevention of carious lesions due to it reducing microbial levels
in formed dental biofilm. From the results of the present in vitro research, in order to investigate new techniques for approaching caries, ex vivo/in vivo studies with B. forficata L are
required.
Acknowledgments
The authors thank the Fundação de Amparo à Pesquisa do Estado do Rio de Janeiro (FAPERJ)
and the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES) for
Oral Antibiofilm Effect of Bauhinia 119
financial support. The authors also thank PhD Adrielle Mangabeira for the Bauhinia forficata L. leaves and Cássia de Mattos de Lima for the elaboration of the schematic drawing presented in the methodology. This study constitutes the master’s degree thesis of the
first author.
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Fiorini, J.E., Biologic activity of the hydroalcoholic extract of Bauhinia forficata Link on
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12. Lino, C.S., Diógenes, J.P.L., Pereira, B.A., Faria, R.A.P.G., Andrade Neto, M., Alves, R.S., Viana,
G.S.B., Antidiabetic activity of Bauhinia forficata extracts in alloxan-diabetic rats. Biol. Pharm
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13. Silva, K.L. and Cechinel Filho, V., Plantas do gênero Bauhinia: Composição química e potencial
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14. Lusa, M.G. and Bona, C., Comparative morphological and anatomical analyses of Bauhinia
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review of the current scenario and its future needs. Pharmacogn. Rev., 9, 87–92, 2015.
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Brunitti, I.L., Evaluation of the spouted bed dried leaf extract of Bauhinia forficata for the treatment of experimental diabetes in rats. Afr. J. Biotechnol., 9, 7165–73, 2010.
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27. Tanner, A.C., Mathney, J.M., Kent, R.L., Chalmers, N.I., Hughes, C.V., Loo, C.Y., Pradhan, N.,
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8
Antimicrobial Effect of a Cardamom Ethanolic
Extract on Oral Biofilm: An Ex Vivo Study
Marina Fernandes Binimeliz1, Mariana Leonel Martins1, Julio Cesar Campos Ferreira Filho1,
Lucio Mendes Cabral2, Adriano Gomes da Cruz3, Lucianne Cople Maia1
and Andréa Fonseca-Gonçalves1*
1
Department of Pediatric Dentistry and Orthodontics, School of Dentistry, Universidade Federal do
Rio de Janeiro (UFRJ), Rio de Janeiro, Brazil
2
Department of Pharmaceutics, Faculty of Pharmacy, Universidade Federal do Rio de Janeiro (UFRJ),
Rio de Janeiro, RJ, Brazil
3
Food Department, Federal Institute of Education, Science and Technology of Rio de Janeiro (IFRJ),
Rio de Janeiro, RJ, Brazil
Abstract
Elettaria cardamomum, known as the small cardamom, belongs to the Zingiberaceae family and grows
in rainforest. Its seeds contain a volatile oil that is used for culinary purposes but which also has pharmacological properties. However, knowledge of its antimicrobial potential against oral biofilm remains
scarce. The present book chapter proposes to demonstrate the effect of an Elettaria cardamomum ethanolic extract (ECE) against oral biofilm bacteria through an in vitro study. The ECE’s composition (e.g.,
moisture, proteins, fat) was also evaluated. Antibacterial activity of the ECE for Streptococcus mutans and
Lactobacillus casei was investigated as part of an ex vivo experiment. Salivary samples of children were collected, homogenized (saliva pool), and spread (20 µL) on cellulose membranes over brain heart infusion
agar for biofilm formation (5% CO2, 37°C). After 48 h, the cellulose membranes were treated for 1 min
with the following (n = 4), respectively: 0.12% chlorhexidine, ECE (7.34 mg/mL), ECE × 2 (15.45 mg/
mL), and deionized water. Microorganisms were quantified after treatment and analyzed by analysis of
variance/Tukey’s test (α = 5%). The ECE presented moisture = 13.04 ± 0.48 g/100 g, proteins = 9.62 ± 0.54
g/100 g, and fat = 2.74 ± 0.40/100 g. The ECE thus presents antibacterial activity against the tested microorganisms and reduces the microbial viability levels of a biofilm formed from a pediatric saliva pool. As
such, this chapter aims to present a review and discussion about the oral antibiofilm effect of cardamom.
Keywords: Antibacterial agents, biofilms, laboratory research
8.1 Introduction
Caries disease is a condition caused by acidophilic microorganisms that metabolize fermentable sugars. In this regard, dental caries is seen as a consequence of an imbalance in
*Corresponding author: andrea.goncalves@odonto.ufrj.br; andreagantonio@yahoo.com.br
Durgesh Nandini Chauhan, Prabhu Raj Singh, Kamal Shah, and Nagendra Singh Chauhan (eds.)
Natural Oral Care in Dental Therapy, (121–132) © 2020 Scrivener Publishing LLC
121
122 Natural Oral Care in Dental Therapy
the resident microbiota due to frequent pH drops in the biofilm. Thus, situations of a diet
rich in sugars or a reduction in the saliva amount, due to their ability to buffer the acids, are
predisposing factors for the appearance of carious lesions [1, 2].
It is known that the removal of the dental biofilm, commonly performed by mechanical
methods, is extremely important for the control of dental caries. However, in children and
adolescents with orthodontic appliances, factors such as individual motivation and monitoring limit the effectiveness of brushing. These individuals also have difficulty in maintaining adequate control of the biofilm, particularly in interproximal sites, often requiring the
use of chemical agents for the control of such [3].
Among the antimicrobials with action on several microorganisms, chlorhexidine is one
of the most studied agents and is consecrated as the most effective and potent compound in
buccal mouthwashes [4, 5]. This substance can still be found in dentifrices, gels, varnishes, or
solutions [3, 6], being widely used as a positive control for tests of the efficacy of other antimicrobial agents [7, 8]. However, despite its proven efficacy, its use in dentifrices, for example,
may be undue as a result of inactivation by anionic ingredients [3, 6] and by the presence of
detergents such as sodium lauryl sulfate, which are incompatible with its composition and
thus consequently reduce its antimicrobial potential. Another issue worth mentioning is the
cytotoxicity produced and the amount of adverse effects caused by prolonged use of chlorhexidine. Among them, the following stand out: dental pigmentation, loss of gustatory sensitivity,
desquamation of mucosa, and resistance of microorganisms with prolonged daily use [9].
In this perspective, new phytotherapeutic compounds have been investigated [10]
and some studies claim that natural antimicrobial agents incorporated into dentifrices or
mouthwashes may be as effective as chlorhexidine digluconate for immediate and delayed
bacterial death in oral biofilms [10–12].
The Elettaria cardamomum, known as the small cardamom, belongs to the Zingiberaceae
family and grows in rainforest with elevations ranging from 762 to 1524 m, with rain amounting to 381 cm annually. Commercially grown in India, Sri Lanka, Guatemala, and Tanzania, its
fruits have thin walls and are smooth and oblong, containing 15 to 20 aromatic, reddish-brown
seeds. These seeds contain a volatile oil that is used for culinary purposes but which also boasts
pharmacological properties including in the management of gastrointestinal, cardiovascular,
and neural disorders [13, 14]. In addition, there are studies that have reported anticarcinogenic,
antiulcerogenic, and antimicrobial actions of Elettaria cardamomum against important colonizers of oral sites, such as Candida albicans and Streptococcus mutans [15]. However, knowledge of its antimicrobial potential against oral biofilm remains scarce. In the present book
chapter, we present and discuss the results of an evaluation of the antimicrobial effect of the
ethanolic extract of Elettaria cardamomum against isolated microorganisms and oral biofilm.
8.2 Materials and Methods
8.2.1 Cardamom Extract Production
The seeds of Elettaria cardamomum, in the crude form, were crushed and sifted in a 0.6-mm
sieve (Figures 8.1 and 8.2). The extract was then prepared at the Pharmaceutical Industrial
Technology Laboratory at the Centro de Ciências da Saúde (CCS) of the Universidade Federal
do Rio de Janeiro (UFRJ), as follows: 30 mL of 80% ethanol was added to 10 g of the Elettaria
Antibiofilm Effect of Cardamom 123
Figure 8.1 Cardamom seeds. Personal file.
Figure 8.2 Cardamom seeds. Personal file.
cardamomum crushed plant. The mixture was heated at 60°C for 30 min with stirring and
then filtered on Whatman paper no. 2 and centrifuged at 7,500 g at 5°C for 10 min. The final
extract concentration was 33.3%, and the supernatant was directly used in the experiments.
8.2.2 Physical Analyses
The physical analyses were also performed at the Pharmaceutical Industrial Technology
Laboratory. The approximate compositions of total solids, proteins, and fat content of the
extract were determined according to standard procedures [16]. The total solids were determined gravimetrically after 24 h of drying of the Elettaria cardamomum extract (ECE) in
the oven (Micronal, São Paulo, Brazil). Protein levels were determined using the Kjeldahl
method, based on total sample nitrogen, with subsequent correction using a conversion
factor of 6.38. Fat was determined by the method of Gerber [17].
8.2.3 Bacterial Strains and Determination of Minimum Inhibitory
Concentration and Minimum Bactericidal Concentration
Strains of S. mutans (American Type Culture Collection no. 25175) and Lactobacillus
casei (L. casei; American Type Culture Collection no. 393) were used to determine the
124 Natural Oral Care in Dental Therapy
antibacterial activity of the extract. Initially, the degree of purity of the bacterial samples
was checked. Then, isolated bacterial colonies were screened and transferred to 0.85% saline
until reaching an optical density of 0.13 at a 625 nm wavelength (S2 Colorimeter; Biochrom,
Cambridge, UK), corresponding approximately to an inoculum of 108 colony-forming units
(CFU)/mL. In order to evaluate the antibacterial activity of the ECE against the mentioned
microorganisms, the minimum inhibitory concentration (MIC) and minimum bactericidal concentration (MBC) were determined, according to the protocol of the Clinical and
Laboratory Standards Institute [18] and the modification proposed by da Cunha et al. [19].
In this perspective, 100 μL of brain heart infusion culture medium (BHI; Difco, Sparks, NV,
USA) was inserted into each well of two 96-well microplates (Kasvi-São José dos Pinhais,
Paraná, Brazil). Thereafter, each first test well received 100 μL of the ECE or 0.12% chlorhexidine digluconate (pharmacological control) and the microdilution process was performed, which consisted of transferring 100 μL of each first test well to the subsequent well.
Then, 100 μL of the last well was discarded so that all had the same volume (100 μL). Finally,
5 μL of the inoculum was inserted into each well in order to obtain a final concentration
of 5 × 105 CFU/mL. The tested concentrations of ECE ranged from 97.56 to 0.036 mg/mL,
while that of chlorhexidine digluconate ranged from 58.536 to 0.022 mg/mL.
The MIC was defined as the lowest concentration of the solution that did not allow visible microbial growth, which was confirmed by the application of a 0.01% suspension of
resazurin (Sigma-Aldrich, St. Louis, MO, USA), while the MBC was determined as the
lowest concentration that was able to cause the death of all microorganisms. This was verified by a subculture of 50 μL of MIC and above concentrations on BHI agar, which were
incubated for 48 h (37°C, 5% CO2) [20].
8.2.4 Salivary Collection for Biofilm Formation (Ex Vivo Experiment)
The study was approved by the Ethics in Local Research Committee of the UFRJ (CAAE:
67020617.8.0000.5257, opinion 2.060.371), and for this stage, parents or guardians for the
involved children signed a free consent term and approved the collection of the saliva of
their children. Thus, children (n = 3) seen at the pediatric dentistry clinics of the Department
of Pediatric Dentistry and Orthodontics of the UFRJ, with a mean age of 9.33 ± 0.57 years
and who were in good health without the use of antibiotics or antibacterial mouthwash in
the last 30 days prior to collection were selected. The mean number of decayed, missing,
and filled teeth (DMFT) of these children (DMFT = 7.67 ± 3.05) and mean total salivary
flow (0.64 ± 0.05 mL/min) were also recorded. The children were instructed not to consume
food or drink except water within 1 h prior to saliva collection.
The unstimulated saliva produced in the first 30 seconds was discarded and then collected for exactly 5 min in sterile test tubes. Saliva samples were immediately taken to the
Multidisciplinary Laboratory of Dental Research (MLDR) at the Faculty of Dentistry of the
UFRJ for the development of the biofilm formation stage.
8.2.5 Biofilm Formation and Treatment
Microbiological assays for biofilm formation were conducted according to the methodology proposed by Antonio et al. [21]. Here, 1 mL of saliva from each volunteer was placed
in a single tube, which was vortexed for one minute, resulting in a saliva pool. An aliquot
Antibiofilm Effect of Cardamom 125
(20 μL) of the pool was placed on the surface of cellulose membranes (N = 20) with a 13 mm
diameter (Millipore Corp., Billerica, MA, USA), located on Petri dishes with BHI medium.
The system was incubated for 48 h (37°C, 5% CO2) to form a mature biofilm (Figure 8.3).
Following biofilm formation, each membrane disk was carefully removed with sterile
tweezers and placed for 1 min in tubes containing the test substances (2 mL) according to
the following treatment groups (n = 4): 0.12% chlorhexidine, ECE (7.34 mg/mL), ECE × 2
(15.42 mg/mL), and deionized water (Figure 8.4). The biofilm formed on the membranes
Figure 8.3 Biofilm formed over the surface of cellulose membranes placed on Petri dishes with BHI medium.
Figure 8.4 Treatment of biofilm formed over a membrane disk for 1 min in a tube containing the test
substance (2 mL) according to the following treatment groups: 0.12% chlorhexidine, ECE (7.34 mg/mL),
ECE × 2 (15.42 mg/mL), and deionized water.
126 Natural Oral Care in Dental Therapy
of the growth control group did not receive any type of treatment. Serial dilutions (100 to
10−8) were performed for viable cell counts, considering the number of total microorganisms. The experiment was performed in duplicate and the results expressed in Log10 CFU/
mL (Figure 8.5).
(a)
(b)
(c)
(d)
Saliva pool
Vortex
1min
48h at 37°C
with 5% CO2
20 µL
cellulose membrane
disks 13 mm diameter
N = 20
n=3
(e)
(f)
2 mL
1 min
F1) 0,12% Chlorhexidine
F2) ECE (7.34 mg/mL)
F3) ECE × 2 (15.42 mg/mL)
F4) Deionized water
F5) Growth control (without treatment)
Treatment
n=4
(g)
Cardamom seeds
(h)
50 µL
100 µL
each
10−4
100
10−1
10−2 10−3
(i)
(j)
Log10 CFU/mL
10−5 10−6 10−7 10−8
48 at 37°C
with 5% CO2
Figure 8.5 Schematic drawing of the experimental model with oral biofilm. (a) Collection of the saliva of
three children; (b) Pediatric saliva pool formed from 1 mL of saliva from each volunteer; (c) An aliquot
of the pool was placed on the surface of cellulose membranes disks; (d) The system was incubated in a
microbiological oven; (e) Each membrane disk was placed for 1 min in tubes containing the test substances;
(f) The biofilms formed were treated with: 0.12% chlorhexidine, ECE (7.34 mg/mL), ECE × 2 (15.42 mg/mL),
and deionized water. The growth control group did not receive any type of treatment; (g) Serial dilutions were
performed for viable cell count; (h) Subculture of 50 μL for evaluate the bacterial viability; (i) Incubation in
microbiological oven; (j) The results were expressed in Log10 CFU/mL.
Antibiofilm Effect of Cardamom 127
8.2.6 Statistical Analyses
Data were analyzed descriptively and by statistical tests using the Statistical Package for
the Social Sciences version 21.0 software program (IBM Corp., Armonk, NY, USA). The
Shapiro–Wilk test was performed to evaluate the normality of the data and analysis of variance with a post hoc Tukey test (p < 0.05) were the tests used to analyze the differences of the
means between the groups in the microbiological test of biofilm treatment.
8.3 Results and Discussion
Although existing literature that has evaluated the antibiofilm activity of ECE with the
methodology similar to the present study is scarce, it is known that the extract of the evaluated seed has as main chemical components the acetate of α-terpinol and 1,8-cineole [22,
23], among other highly bioactive compounds [23]. These compounds have medicinal
properties, such as antimicrobial activity, that are used as phytotherapics. In this sense,
E. cardamomum appears to present significant antibacterial activity and to be useful in the
discovery of new antibiotics. Although there are few studies to date that have performed
a chemical analysis of phenolic content in the composition of cardamom, ferulic, vanillic,
caffeic, and p-coumaric acids [24] have been previously identified, which are associated
with antibacterial activity against S. mutans and an influence on biofilm degradation [25].
The ECE showed a moisture value of 13.04 ± 0.48 g/100 g, a total protein equivalent to
9.62 ± 0.54 g/100 g, and total fat equal to 2.74 ± 0.40 g/100 g. This extract inhibited the
growth of S. mutans at 7.34 mg/mL, which also corresponded to an MBC against S. mutans.
For L. casei, the MIC was 15.42 mg/mL, but the MBC was not found in the concentration
range investigated.
Regarding inhibitory and bactericidal activity, in a study conducted in Turkey [26], the
authors observed a large amount of eucalyptol (1,8-cineol), an oily component, in the investigated Cardamomum species. In that study, the plant species played an important antimicrobial role against Campylobacter spp. Although an investigation of this compound was
not performed in the present study, it is suggested that a great part of the total fat content is
also responsible for the antimicrobial activity demonstrated by the extract tested, since fats
disturb biofilm adhesion [27]. However, further investigations to evaluate the eucalyptol
content of the present extract should be conducted.
In an earlier study, ECE showed inhibitory activity against S. mutans (5 mg/mL),
Staphylococcus aureus (1.25 mg/mL), C. albicans (2.5 mg/mL), and Saccharomyces cerevisiae (5 mg/mL) [15]. Thus, there is agreement with the present study, since similar results
of MIC were observed for S. mutans [15]. Another study [26] found MIC and MBC values
to be between 0.012 and 0.05 μL/mL against Campylobacter jejuni and Campylobacter coli.
However, the difference in comparison with the present study can be explained by the fact
that different strains were tested. The antibacterial activity of several essential oils of the
Zingiberaceae family was verified and, among them, the ECE had an MIC of 2,000 μg/mL,
but no MBC value was found in the concentrations evaluated [25]. The divergence of the
results can be justified by the different strains, microorganisms, and methodologies used;
how the tested substances were prepared (essential oil, extract); and the different parts of
the plant involved (seeds, leaves).
128 Natural Oral Care in Dental Therapy
Considering the inhibitory action against the biofilm formed from the saliva pool, 0.12%
chlorhexidine was the substance that presented the greatest reduction of viable total microorganisms from the biofilm (6.30 ± 0.22 Log10 CFU/mL; p = 0.000). The ECE × 2 finding
(7.10 ± 0.36 Log10 CFU/mL) was better when compared with the untreated group (7.61 ±
0.18 Log10 CFU/mL; p = 0.006) and the group treated with deionized water (7.67 ± 0.16
Log10 CFU/mL). However, ECE, deionized water, and the growth control did not present
statistically significant differences among them (p > 0.05) (Table 8.1).
The 0.12% chlorhexidine was the agent with the greatest efficacy against biofilm microorganisms, ultimately reducing its count by 18.7% (p < 0.05), while ECE and ECE × 2
reduced the number of CFUs, respectively, by 6.4% and 8.3%, without any statistical difference between them.
It is known that high levels of S. mutans are directly related to dental caries [28]. Therefore,
a substance that interferes with growth or reduces the number of these species and also the
total microorganisms of the biofilm are substances that aid in the prevention of carious
lesions [20]. There are some studies in the literature that describe the anticariogenic potential of medicinal plants [29–32]; however, there is a need for new discoveries regarding the
biological properties of these products. In the present study, it was observed that the ECE
presented antimicrobial activity against strains of S. mutans and L. casei and was able to
reduce the microbial viability in the biofilm, suggesting a potential anticariogenic activity
of this product.
In the biofilm assay formed through the saliva pool of children, a reduction in the counts
of viable microorganisms after treatment with both extracts was observed in both the concentrated (ECE × 2) and diluted (ECE) groups, with no statistical difference between them.
The 0.12% chlorhexidine had a higher antibiofilm effect after a single treatment versus the
other groups, but the prolonged daily use of this substance may cause undesirable effects,
such as a loss of taste, pigmentation of the dental elements, and desquamation of the mucosa
mainly due to its toxicity [33]. In addition, it may cause resistance of several pathogenic oral
microorganisms to antibiotics. Therefore, it is important to search for other alternatives such
as natural products that can help to reduce these adverse effects in dentistry, since medicinal
plants have been used for prophylactic and curative purposes since ancient times [34].
Table 8.1 Microbial levels in log10 CFU/mL for each group after
the biofilm assay formed on cellulose membranes.
Treatment group
0.12% chlorhexidine
Bacterial count (SD)*
6.30 (0.22)a
ECE (7.34 mg/mL)
7.25 (0.22)b,c
ECE × 2 (15.42 mg/mL)
7.10 (0.36)c
Deionized water
7.67 (0.16)b
Growth control
7.61 (0.17)b
Different lowercase letters indicate p < 0.05 in the column.
Counts transformed into log10 CFU/mL.
*SD: Standard deviation.
Antibiofilm Effect of Cardamom 129
Some limitations of this study should be considered, including the reduced number of
strains against which the MIC and MBC were evaluated or the number of samples per
group and the surface on which the biofilm was formed (celluloid membranes), since in the
literature studies bovine teeth have been more frequently used for biofilm assays [29, 31].
This is due to the great similarity between bovine and human enamel [35]. Therefore, future
studies should be carried out to analyze the chemical composition and cytotoxic potential
of ECE in different concentrations of the product and on tooth structure (enamel and/or
dentin) in order to complement the present study and confirm the findings.
8.4 Final Considerations
This chapter was carried out with the purpose of evaluating, by means of a study, the
action of ECE on planktonic and oral biofilm microorganisms. No studies were found in
the researched literature that tested ECE against a mixed oral biofilm formed on cellulose
membranes; thus, this is an innovative proposal. In addition, the biofilm was formed from
a saliva pool, representing a situation that is closer to what occurs in the oral cavity in comparison with tests performed with planktonic cells, such as the MIC and MBC.
Ultimately, the ECE showed antimicrobial activity against the tested oral microorganisms
and can reduce the microbial levels of a biofilm formed in vitro by a pediatric saliva pool.
However, further studies are needed to confirm the antibiofilm potential of this product.
Acknowledgment
This study was financed in part by the Coordenação de Aperfeiçoamento de Pessoal de
Nível Superior—Brasil (CAPES)—Finance Code 001. The authors thank Cássia de Mattos
de Lima for the elaboration of the schematic drawing presented in the methodology.
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9
Effect of Punica granatum Peel Extract
on Growth of Candida albicans in Oral
Mucosa of Diabetic Male Rats
Maryam Eidi1* and Fatemeh Noorbakhsh2
1
Department of Biology, College of Biological Sciences, Varamin-Pishva Branch,
Islamic Azad University, Varamin-Pishva, Iran
2
Department of Microbiology, College of Biological Sciences, Varamin-Pishva Branch,
Islamic Azad University, Varamin-Pishva, Iran
Abstract
To survey the oral treatments of Punica granatum L. peel hydro-methanolic extract (0.025, 0.05, 0.1,
and 0.2g/kg, body weight) and itraconazole (0.01 g/kg, body weight) on the growth of Candida albicans (ATCC 10231) in the oral mucosa of alloxan-induced diabetic male rats, the animal was made
diabetic by alloxan (0.15 g/kg, intraperitoneally). After diabetes induction, they were contaminated
by oral administration of Candida albicans. Fungus sampling, culturing in medium and colony count
were done by swabs from mouths of the animal. The period of the experiment was 7 days. On the
second day of plant treatment, the results showed that treatment of extract decreased colony count
of C. albicans in diabetic rats (p < 0.001). The growth of C. albicans is suppressed on the 6th day. The
effect of the plant is similar to itraconazole. So, the consumption of pomegranate extract inhibited
the growth of Candida albicans in the month of diabetic rats.
Keywords: Punica granatum, diabetes, Candida albicans, rat
9.1 Introduction
Herbal medicine is known as the inexpensive and accessible source in the healthcare system
[1]. For thousands of years, the ayurvedic medicine has reduced illness and promoted good
health [2]. The flora of Iran includes abundant medicinal plants. Many medicinal plants
have been consumed in folk medicinal systems and accounted in pharmacopoeia as materials for treating oral fungal pathogens [3]. The medicinal plants have alkaloids, tannins,
essential oils, and flavonoids. There are many species of medicinal plants, which are being
used, traditionally, to control fungal infections [4].
Candida albicans (C. albicans) is one of the chronic pathogens in humans that cause
wounds in the mucosa of the upper digestive organs and vagina. The consumption of
*Corresponding author: maryameidi@gmail.com; eidi@iauvaramin.ac.ir
Durgesh Nandini Chauhan, Prabhu Raj Singh, Kamal Shah, and Nagendra Singh Chauhan (eds.)
Natural Oral Care in Dental Therapy, (133–138) © 2020 Scrivener Publishing LLC
133
134 Natural Oral Care in Dental Therapy
antibiotics, steroids, immunosuppressive agents, and radiotherapy can cause Candida infections [5]. The conditions such as the immunodeficiency syndrome and iron and vitamin
deficiency, which are common in diabetes mellitus (DM) disease, are related to the Candida
infections. The lesion of oral epithelium due to Candida infection causes candidiasis, which
is defined by the abnormal thickened oral mucosa and inflammation [6, 7].
Punica granatum L. (Lythraceae) is also called pomegranate and grown from Iran to
Northern India. The pomegranate is a shrub or small tree [8] with spiny branches and 12–16
feet in height. The fruit is deep red, five inches wide, with thick peel, spherical, and with
pointed calyx. The seeds of the fruit are parted by a white and thin pericarp and environed by
small contents of tart and juice. The leaves of the pomegranate are shiny and 7–8 cm long [9].
The juice, peels, and seed oil of pomegranate contain cyaniding and delphinidin (anthocyanidins), chlorogenic acid, and caffeic acid (phenol compounds), gallic acid, ellagic acid,
luteolin, quercetin, kaempferol, naringenin, 17-alpha-estradiol, estrone, estriol, testosterone, beta-sitosterol, coumestrol, gamma-tocopherol, punicic acid, campesterol, and stigmasterol. They are related to potentials of pomegranate for treating diseases [10, 11].
Since the prevalence of infective diseases in diabetic patients is more numerous, an investigative study was conducted on the antifungal activity of the hydro-methanolic extract of
pomegranate peel in diabetic rats.
9.2 Materials and Methods
9.2.1 Hydro-Methanolic Extract
Fresh Punica granatum L. peels were obtained from Central Province, Iran. A voucher specimen was validated in the herbarium of Islamic Azad University. The peels of the pomegranate were dried in the shade and ground by an Ultra-Torax apparatus. About 50 g of the
powder was soaked in 480 mL of methanol (80%) and kept in the shadow for 72 h. The mixture was filtered and then condensed in low pressure by a rotary evaporator. The product
was 153% (w/w) of the extract and was kept at –20°C until usage. The extract was diluted
by saline, and concentrations of 0.025, 0.05, 0.1, and 0.2 g/kg body weight were made. The
hydro-methanolic extract was treated orally to the alloxan-induced diabetic rats for 7 days.
9.2.2 Candida albicans Inoculation
Candida albicans was purchased from the American Type culture collection (ATCC
10231) and kept at −70°C in TSA medium until usage. Twenty four hours before inoculation, C. albicans was cultured in the medium of sabouraud dextrose agar (SDA) and then
incubated at 37°C. The grown colonies were suspended in saline (5 mL). The suspension
was stirred by vortex for 10 s. The final inoculum concentration of the suspension was
adjusted to 0.5–2.5 × 103 CFU/mL.
9.2.3 Animal
Male Wistar rats (weighing 200–250 g) were bought from the Pasteur Institute and kept
in an animal room at 22 ± 2°C, light/dark cycle at 7 AM to 19 PM and with humidity of
Effect of Punica granatum Peel Extract
135
40–60%. Each animal was used once only. Experiments were performed according to the
guidelines of Branch of Varamin-Pishva, Islamic Azad University, which is in accord with
the institutional use and care of laboratory animal guidelines (NIH, Number of publication,
85-23; revised in 2010; 86/609/EEC European Communities Directive).
Six groups were used in this study. The diabetic groups were made by alloxan (0.15 g/kg
body weight, intraperitoneally). After 5 days, the rats in which the fasting blood glucose was
higher than 180 mg/dL were selected for the research.
The animals were contaminated by oral administration of Candida albicans. After the
growth of fungus in the mouth of the animal, oral treatments of the extract (0.025, 0.05, 0.1,
and 0.2 g/kg body weight) and itraconazole (0.01 g/kg body weight) were made for 7 days.
The sampling, culturing in medium, and colony count of Candida albicans were done by
swabs from mouths of all animals every day. The period of the experiment was 7 days. The
control rats were treated with saline (as the vehicle).
9.2.4 Statistical Analysis
Data were represented as mean ± SEM and analyzed by one-way analysis of variance followed by Tukey post hoc test. A value of p < 0.05 was determined significance.
9.3 Results and Discussion
DM is a metabolic disease and is defined as a deficiency of insulin secretion, insulin action,
or both of them [12, 13]. Many people in the world have DM in 2010, and subsequently, 300
million will have DM by 2025 [14, 15]. DM is related to the various inflammatory diseases
and soft tissue lesions in the oral cavity; however, knowledge of these problems is absent
worldwide [16]. The prevalence of Candida infections and oral candidiasis has been investigated for many years among diabetic people, frequently [17–19].
The present result showed that treatments of extract and itraconazole inhibited the growth
of C. albicans in experimental diabetic groups compared to control diabetic rats on the second
day of the treatment period, significantly. Extracts of pomegranate and itraconazole reduced
the colony count of C. albicans, significantly (p < 0.001). The growth of C. albicans is suppressed on the 6th day. The significance of extract was similar to itraconazole (Table 9.1).
In the agreement, Mansourian et al. reported a significant antifungal effect of Punica
granatum extract against C. albicans by the well diffusion method (in vitro) [20].
Hayouni et al. showed the significant antifungal activity of pomegranate against C. albicans in guinea pigs. The plant extract also affected wound healing in guinea pigs [21].
Endo et al. isolated one of the significant components from pomegranate peel, which
is called punicalagin. They showed its strong antifungal activity against C. albicans. It is
reported that the treatment of punicalagin and fluconazole inhibited the growth of C. albicans (in vitro) and showed a synergistic effect [22].
Madugula et al. showed that the minimum inhibitory concentration of P. granatum peel
is equal to clotrimazole in vitro, and both of them inhibited the growth of Candida species,
significantly (p < 0.05) [23].
Tehranifar et al. showed that the pomegranate is a powerful antioxidant and antifungal
substance. It is shown that the methanolic extract of pomegranate inhibited mycelial growth
136 Natural Oral Care in Dental Therapy
Table 9.1 Effects of oral treatment of Punica granatum peel extract at concentrations of 0.025,
0.05, 0.1, and 0.2 g/kg and itraconazole (0.01 g/kg) on the colony count of C. albicans.
Extract (g/kg)
Day
Control
5
0.025
5
0.05
5
0.1
0.2
5
Itraconazole
5
0
>10
>10
>10
>10
>10
>105
1
>105
2906 ± 1043
***
+
341 ± 11
***
353 ± 30
***
30 ± 3
***
726 ± 165
***
2
>105
1109 ± 334
***
++
132 ± 15
***
87 ± 39
***
8±1
***
215 ± 93
***
3
>105
204 ± 72
***
101 ± 10
***
14 ± 4
0
60 ± 37
***
4
>105
166 ± 57
***
+++
33 ± 10
***
0
0
0
5
>105
8±3
***
14 ± 4
***
+++
0
0
0
6
>105
0
0
0
0
0
7
>105
0
0
0
0
0
***p < 0.001 shows significance from control diabetic group, +p < 0.05, ++p < 0.01, +++p < 0.001 show
significance from itraconazole group.
and spore germination of Candida species, strongly. On the other hand, inhibitory effects of
the seed and peel of pomegranate is higher than its leaf (2.8-fold). The antioxidant potential
of the seed, peel, and leaf extracts were measured as 55%, 36%, and 16%, respectively. So,
the great content of phenolic compounds in the extracts of the peel and seed could cause the
potent antioxidant and antifungal and antioxidant activities of pomegranate [24].
9.4 Conclusion
The present study indicated that the hydro-methanolic extract of pomegranate peel has an
antifungal effect against C. albicans and reduces the growth of C. albicans in diabetic rats.
Acknowledgment
The authors thank the Deputy Research of the Varamin-Pishva Branch, Islamic Azad
University, for support of the project.
Effect of Punica granatum Peel Extract
137
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12. Beverley, B. and Eschwège, E., The diagnosis and classification of diabetes and impaired glucose tolerance, in: Textbook of Diabetes 1, Third edition; Pickup, J.C. and Williams, G. (Eds.),
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14. King, H., Aubert, R., Herman, W., Global burden of diabetes, 1995–2025. Prevalence, numerical estimates and projections. Diabetes Care, 21, 1414–1431, 1998.
15. Zimmet, P., Globalization, coca-colonization and the chronic disease epidemic: Can the
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16. Al-Maskari, A.Y., Al-Maskari, M.Y., Al-Sudairy, S., Oral manifestations and complications of
diabetes mellitus: A review. Sultan Qaboos Univ. Med. J., 11, 179–186, 2011.
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diabetic subjects. J. Assoc. Physicians India, 53, 599–602, 2005.
18. Shirmali, L., Astekar, M., Sowmya, G.V., Correlation of oral manifestations in controlled and
uncontrolled diabetes mellitus. Int. J. Oral Maxillofac. Pathol., 2, 24–27, 2011.
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Part III
APPLICATIONS OF NATURAL
PRODUCTS IN ORAL CARE
10
Effect of Oil Pulling on Oral Health
Sameer Anil Zope* and Siddhartha Varma
Department of Periodontology, School of Dental Sciences, Krishna Institute of Medical Sciences
Deemed to be University, Karad, India
Abstract
Oil pulling has been used widely as a conventional Indian folk remedy for many years for strengthening teeth, gingiva, to prevent dental caries, halitosis, bleeding gums, dryness of mouth, and
cracked lips. In the Ayurveda literature Charaka Samhita (Sutrasthana 5, 78–80), it is referred to as
Gandoosha, Kavala, and Kavala Graha. It is claimed to treat about 30 systemic disorders ranging
from diabetes to migraine and asthma. A Ukrainian medical practitioner, Dr. F. Karach, acquainted
the remarkable notion of oil pulling in the 1990s. Recent studies on oil pulling therapy using sunflower and sesame oil were found to reduce dental caries and plaque-induced gingivitis. The most
amazing part of oil pulling therapy is that it can be performed using any cold pressed oil easily at
home such as coconut, sunflower, or sesame oil; hence, it becomes a very cost-effective modality. Since last decade, there are many studies available on the use of oil pulling for the maintenance of overall oral health. There is mounting evidence of oil pulling being as good as many other
chemical-containing ointments, toothpastes, or mouthwashes in control of oral problems with no
untoward side effects. This chapter overviews the evidence-based use of oil pulling therapy in the
maintenance of oral health.
Keywords: Ayurveda, dental caries, gingivitis, oral malodor, oil pulling, oral hygiene
10.1 Introduction
The oral cavity is considered the reflection of systemic health. Oral health is an integral and
fundamental part of the overall health and is considered as most important to everyone.
The World Health Organization (WHO) defined oral health as a state of being free from
chronic mouth and facial pain, oral and throat cancer, oral sores, birth defects such as cleft
lip and palate, periodontal (gum) disease, tooth decay and tooth loss, and other diseases
and disorders that affect the oral cavity [1].
This implies that oral health significantly impacts the general health and well being of
an individual. In recent years, various studies have provided unequivocal evidence on the
*Corresponding author: aoldentist@gmail.com
Durgesh Nandini Chauhan, Prabhu Raj Singh, Kamal Shah, and Nagendra Singh Chauhan (eds.)
Natural Oral Care in Dental Therapy, (141–152) © 2020 Scrivener Publishing LLC
141
142 Natural Oral Care in Dental Therapy
strong interrelationship between systemic and oral diseases. It is believed that this relationship is due to common risk factors shared between various diseases.
Oral hygiene maintenance is very important for all individuals, and it includes
mechanical tooth cleaning with the additional adjunctive use of a chemical/herbal agent
for reducing plaque formation. Apart from mechanical plaque control methods, research
has been focused on chemotherapeutic agents for preventing or reducing plaque-induced
oral diseases. Widely used various chemical plaque control agents like chlorhexidine and
cetylpyridinium chloride mouthwash have their own disadvantages like brown staining
of teeth and oral appliances, increased formation of tartar, temporary alteration of taste,
oral dryness, and burning sensation of the oral mucosa. Alcohol-containing mouthwash
may result in dry mouth and worsening of halitosis [2]. Drug toxicity, adverse effects, and
antibiotic resistance to modern drugs have encouraged scientists to research on natural
products.
A number of other alternatives have been put forward in order to overcome these problems; among those, the procedure of oil pulling is the one which has no side effects if used
properly. It can be performed using readily available edible oils in the household. Recently,
various forms of alternative or traditional medicinal treatments, such as Ayurveda, have
started to gain popularity, due to their natural origin, cost effectiveness, negligible side
effects, and improved patient compliance.
Ayurveda is a form of traditional holistic medicinal system originating in the Indian
subcontinent region. Its advent and practice in the region reportedly date back about 3000–
5000 years. Recently, it has gained popularity as a complementary medicine in other parts
of the world [3].
10.2 What is Oil Pulling (Snaihik Gandoosh)?
Oil pulling has been an extensively used procedure as a conventional Indian folk remedy
for many decades for strengthening of the gingiva, teeth, cracked lips, and dryness of the
throat. In Ayurveda text Charaka Samhita (Sutrasthana 5, 78–80), it is mentioned as Kavala,
Gandoosh/Kavala Graha, and it is claimed to treat about 30 systemic illnesses ranging from
migraine headaches to asthma and diabetes. Dr. F. Karach popularized the oil pulling concept in the late 1990s in Russia.
Oil pulling (Snaihik Gandoosh), as the name suggests, involves vigorous swishing of
oil in the oral cavity to achieve local and systemic benefits, similar to the modern day
use of mouthwashes and oral rinses. It has been used for centuries for the treatment and
Figure 10.1 Procedure of oil pulling.
Effect of Oil Pulling on Oral Health
143
prevention of various oral and systemic diseases, using edible oils derived from sesame,
coconut, and sunflower [4]. Various studies on oil pulling therapy as an adjunct to conventional oral hygiene measures using sesame oil, sunflower, coconut, and olive oil have shown
promising results in the control of oral diseases (Figure 10.1). Scientific evidence reports
that oil pulling therapy may reduce plaque and gingival index scores by reducing the total
oral bacterial count.
10.3 How Does Oil Pulling Work?
While there are numerous theories, the exact mechanism of action is unclear. One theory speculates a mechanism involving alkali hydrolysis of fat, resulting in saponification
or “soap making” process. The fat content of the oils used for oil pulling undergoes an
alkali hydrolysis process and emulsifies the fat into bicarbonate ions, a normal constituent found in the saliva. The resultant soaps are effective cleaning agents, which blend
in the oil, hence, increasing the total surface area of the oil, which in turn increases the
cleansing action [5].
An in vitro study by Asokan et al. revealed that under the microscope, in the 5-min
oil-pulled sample, the oil remained as relatively large globules. Very few numbers of Grampositive bacteria and foreign fibrous particles were seen. With the progressing time from
10 to 15 min, the oil droplets became smaller, revealing more colonies of Gram-positive
bacteria and few squamous epithelial cells. The smaller fractionation of oil globules was
suggestive of the ongoing emulsification process as a result of the agitation of the oil in the
mouth. Hence, it was inferred that this vigorous swishing process may be responsible for
the formation of a soapy layer.
Another theory suggests that inhibition of plaque formation was due to the viscous
nature and emulsification process of the oil, which interferes with microbial adhesion,
coaggregation of bacteria, and removal of the superficial worn-out squamous cells [6].
Furthermore, the third theory hypothesizes that the inherent antioxidants found in the
oil result in detoxification by prevention of lipid peroxidation and exerting an antimicrobial effect [7].
10.4 Composition and Various Activities of Most Commonly
Used Oils for Oil Pulling
Composition and various activities of most commonly used oils for oil pulling are described
in Tables 10.1 and 10.2.
10.4.1
10.4.1.1
Sesame Oil
Antioxidant Activity
Sesame (Sesamum indicum, Pedaliaceae) is a very old cultivated crop and thought to
have originated in Africa. Antifungal activity has been demonstrated by Chlorosesamone
144 Natural Oral Care in Dental Therapy
Table 10.1 Various edible oils used for oil
pulling.
Various edible oils used for oil pulling
1) Sesame oil
2) Coconut oil
3) Olive oil
4) Sunflower oil
5) Rice bran oil
6) Soya bean oil
7) Palm oil
8) Corn oil
Table 10.2 Activities of oils used for oil pulling.
General activities of oils used for oil pulling
1) Emollient
2) Antibacterial
3) Antifungal
4) Antiviral activity
5) Anti-nociceptive
6) Anti-inflammatory
7) Antioxidant
8) Anti-ulcer activity
obtained from sesame roots, while Sesame lignans have antioxidant activities. Large
amounts of unsaponifiable substances, sesamolin and sesamin, have been found in the
sesame oil. Both sesamin and sesamolin increases both the peroxisomal and the hepatic
mitochondrial fatty acid oxidation rate. The unsaponifiable fraction (sesaminol, sesamin,
and sesamolin), a class of substances, which is not found in other oil fats, can probably
protect the oral cavity from inflammation and infection by its antioxidant property [7].
Consumption of Sesame seed appears to enhance vitamin E activity and increases plasma
gamma-tocopherol, which is believed to prevent heart disease and cancer [8].
10.4.1.2
Antimicrobial Activity
A study was conducted to assess the anti-microbial activity of sesame oil against selected
gram-negative and gram-positive microorganism [Bacillus subtilis (NCIM 2480),
Staphylococcus aureus (NCIM 2602), Escherichia coli (NCIM 2981), Salmonella typhi
(NCIM 2493), Proteus vulgaris (NCIM 2813), Cornebacterium diphtheria, Streptomyces gresius]. The author reported that the sesame oil demonstrates excellent antimicrobial activity
with a zone of inhibition range that equals with the standard Kenamycin [9]. A phytochemical screening of sesame oil using gas chromatography mass spectrometry (GC-MS)
revealed the presence of essential oils primarily the carboxylic and phenolic acids groups,
which are responsible for its antimicrobial activity [10].
Effect of Oil Pulling on Oral Health
10.4.2
145
Coconut Oil
Coconut oil is one of the most commonly used oil in the soap industry as it has a high
saponification value. It was also proposed that the salivary alkalis can react with the coconut oil leading to the saponification process and formation of a soap-like substance, which
results in reduced adhesion of plaque [2].
10.4.2.1
Antibacterial, Antifungal, and Antiviral Activity
Oral microorganisms produce many long-chain fatty acids and medium-chain fatty acids as
end products of their metabolism. These fatty acids can potentially contribute to biological
and ecological interactions among the oral pathogens residing in the biofilm.
The fatty acid-producing pathogens are present in both periodontitis and dental caries. Fatty acid production could contribute to a natural “nutrient reservoir” in oral plaque
biofilms, resulting in mutual relationships with other oral bacteria. Free fatty acids (FFAs)
present in coconut oil result in competitive inhibition of oral organisms by competing with
fatty acids produced by pathogens [11].
Medium-chain monoglycerides, especially monolaurin found in coconut oil, are effective in destroying a wide variety of lipid-coated Gram-positive and Gram-negative microorganisms by disrupting their lipid membrane and inhibiting enzymes required in nutrient
transfer and energy production, leading to the death of the bacteria. In a recent study, coconut oil has demonstrated a significant antifungal activity, which is comparable with ketoconazole against various strains of Candida spp [12].
Coconut oil is extremely effective against a variety of lipid-coated viruses such as influenza virus, visna virus, cytomegalovirus, Epstein–Barr virus, leukemia virus, hepatitis virus,
and pneumonia virus. The virucidal activity of monolaurin is attributed to solubilization of
the phospholipids and lipids in the envelope leading to the disintegration of the viral particles and interference with virus maturation [13].
10.4.2.2
Antinociceptive, Anti-Inflammatory, Antioxidant,
and Anti-Ulcer Activity
Antinociceptive virgin coconut oil (VCO) most likely inhibits the prgressive phase of
chronic inflammation. During the inflammatory process, release of lysosomal enzymes by
phagocytic cells damage the surrounding cells. The anti-inflammatory activity of VCO may
be attributed to its inhibitory effect on the activity of inflammatory cell and/or the lysosomal membrane stabilization. VCO inhibits the release and/or synthesis of these inflammatory mediators such as prostaglandins, bradykinin, and histamine responsible for pain
and edema formation [14].
Antiulcer activity of VCO could be attributed to its FFAs content. Some of these FFAs
possess antioxidant effects (i.e., palmitic acid and myristic acid) and anti-inflammatory
activities (i.e., oleic acid, linoleic acid, and lauric acid). The antiulcer activity of the edible
oils could be associated with their anti-inflammatory and antioxidant activities and the FFA
composition. This activity may contribute to the reduction in gingival bleeding and healing
time of ulcerative lesions of the oral cavity [15].
146 Natural Oral Care in Dental Therapy
10.5 Procedure of Oil Pulling
Ideally, the oil pulling procedure or snaihik gandoosh is usually carried out early in the
morning and on an empty stomach by swishing a tablespoon full of oil vigorously around
the mouth. In children older than 4 years of age, one teaspoon of oil is used. The ideal
quantity is the “half-full mouth.” While swishing the oil all around the mouth, it is forced
and “pulled” in between all the teeth. Oil is to be pulled inside the mouth cavity until there
is uncontrollable salivation (the patient knows it as the quantity of the liquid inside the
mouth cavity increases, which the patient feels by himself). At the end of this correctly done
activity, the viscous oil usually becomes thinner and milky white. After that it is spit out and
clean tap water or warm water is used to thoroughly wash the mouth. Then it is followed
by teeth cleaning with the fingers or regular tooth brushing. If the jaw muscle fatigues,
then the procedure can be carried just for 5 to 10 min. Importantly, during oil pulling, care
should be taken to avoid swallowing or aspiration of oil as the pulled oil contains toxins
and bacteria. Because of the risk of aspiration, it is contraindicated in children younger
than 5 years. Ideally, oil pulling is practiced in a sitting position with chin up. To hasten the
healing effects, it can be practiced three times daily on an empty stomach before every meal.
In conditions like vomiting tendency, oral ulcers, asthma, fever, where tooth brushing is
not easily possible, oil pulling can be beneficial in the maintenance of oral hygiene [16, 17].
10.6 Effects of Oil Pulling on Oral Health
The effects of oil pulling on oral health are found in Table 10.3.
10.6.1
Dental Caries
The oral cavity is always covered with a biofilm. The chemical and mechanical removal of
the oral biofilm is important in maintaining the ecological equilibrium of the oral cavity
and preventing the initiation of the carious process. An estimated 700 different species of
bacteria are found in the oral microbiome, inhabiting the oral biofilm. In dental caries or
tooth decay, bacterial metabolic processes metabolized carbohydrates present in food stuck
on the teeth to an acid, which in turn demineralizes the hard tooth structure. After the pH
of plaque drops below the “critical value” (5.5 for hydroxyapatite, 4.5 for fluorapatite, and
Table 10.3 Effect of oil pulling on oral health.
Effect of oil pulling on oral health
1) Reduction in mucosal inflammation
2) Reduction in gingival bleeding
3) Reduction in halitosis
4) Reduction in caries activity
5) Early healing of ulcerative lesions
6) Soothing effect on oral mucosa
7) Reduction in burning mouth
8) Reduction in mucosal dryness
Effect of Oil Pulling on Oral Health
147
6.7 for cementum), the demineralization process starts, causing disintegration of the calcium phosphate ions in the hydroxyapatite crystals. The demineralized form of enamel is
known as dental caries [5].
Streptococcus mutans and Lactobacillus are two groups of lactic acid-producing pathogens that are mainly associated with dental caries [18].
Asokan S et al. compared the efficacy of sesame oil pulling and chlorhexidine mouthwash in controlling plaque-induced gingivitis. At the end of the study period, significant
reduction was observed in the baseline and post follow-up values of the modified gingival,
plaque index scores, and total bacterial colony count of aerobic dental plaque microorganisms in both the study and control groups. Intergroup comparison did not show statistical
difference in any of the test parameter [6].
Anand et al. investigated the effects of sesame oil pulling on S. mutans and L. acidophilus
colony counts in patients with dental caries. At the initial visit, participants were asked to gargle
with a normal saline solution followed by the collection of salivary samples for analysis of the
total colony counts. The colony counts were assessed at baseline and 40th day. Post follow-up
data revealed an average reduction of 20% in the total colony count. The Snyder method was
used to determine caries susceptibility. The antimicrobial activity of sesame oil against bacterial strains of L. acidophilus and S. mutans was assessed measuring the zone of inhibition. All
the participants exhibited marked reduction in caries susceptibility and demonstrated moderate inhibitory effects against total bacteria counts, S. mutans and L. acidophilus [8].
Various other studies have reported that coconut oil gargling is as effective as using
chlorhexidine mouthwash in decreasing S. mutans and Lactobacillus count. The synergistic
effect of the saponification, emulsification, and the antimicrobial effects of medium-chain
fatty acids present in coconut oil may contribute in the reduction of cariogenic microorganisms [19–21].
10.6.2
Plaque-Induced Gingivitis
Gingivitis is the mildest and most common form of the periodontal disease usually caused
by poor oral hygiene. It is characterized by inflammation, bleeding, and swelling of the
gums. The main etiology of gingivitis is an accumulation of plaque on the surface of the
teeth and gums. In a global scenario, gingivitis begins in the early childhood aged 3–11
years, and the prevalence rises to 70–90% at puberty [2].
Kaliamoorthy et al. study to compare the effect of oil pulling utilizing coconut and sesame oil in 60 patients with plaque-induced gingivitis. All the patients were divided into
three groups Each group was advised a different method of treatment like coconut oil for
oil pulling, sesame oil for oil pulling, and routine toothbrushing alone. Clnical evaluation
was done at baseline, 7th, 14th, and 21st day. At the end of the study, the authors concluded
that coconut oil pulling is a useful and effective oral hygiene practice along with routine oral
hygiene practice. Coconut oil is very effective compared to sesame oil in the reduction of
severity of gingivitis [22].
Amith and colleagues assessed the efficacy, acceptability, and safety of oil pulling in
controlling plaque-induced gingivitis. In a 45-day follow-up study, 10 male subjects were
advised oil pulling with refined sunflower oil in addition to their routine oral hygiene practices throughout the study. All the clinical indices recorded at baseline, days 15, 30, and 45
revealed significant decrease in mean plaque scores from baseline to day 45. At the end of
148 Natural Oral Care in Dental Therapy
the study, no adverse reactions to soft or hard tissues were reported. Even though the oil
pulling procedure was time consuming and difficult to master, 80% of the survey participants expressed acceptability of the oil pulling regimen and were ready to use oil pulling
therapy for the rest of their lives [23].
In a two-phase study, Busscher et al. investigated the antibacterial and clinical efficacy of a vegetable oil-based oral rinse. In vitro inhibition of bacterial growth was studied against microorganisms linked with dental caries and gingivitis. Bacterial strains of
Streptococcus sanguis, Streptococcus mutans, Lactobacillus acidophilus, Veillonella alcalescens, and Actinomyces viscosus were isolated from humans and multiplied overnight in
broth. Authors of the study reported that two strains commonly associated with dental
caries (S. mutans and V. alcalescens) were strongly suppressed by the vegetable oil-based
oral rinse. On the basis of these in vitro study findings, the authors conducted a short clinical trial to assess and compare the clinical efficacy of a vegetable oil-based oral rinse and
six commercially available products: Prodent, Hibident, Meridol, Veadent, Merocet, and
Listerine. All clinical parameters were assessed at baseline 14th and 20th day. Subjects were
advised to continue routine brushing with non-fluoridated dentifrice along with the use of
only their allocated rinse, twice daily, for 30 s. Researchers suggested that the almond oilbased mouth rinse had shown promising results in reducing gingival index scores, which
are comparable to the tested commercially available products [24].
In a randomized controlled trial, Dani N et al. studied the antiplaque activity of sesame
oil pulling and its effect on plaque-induced gingivitis. Forty subjects randomly divided in
two groups were subjected to routine scaling and root planing. Thereafter, the first group
was instructed to carry out oil pulling for 14 days; while the second group was given chlorhexidine mouthwash for 14 days. The authors reported that both the groups showed significant reduction in all parameters like gingival index scores, Plaque index scores, and total
aerobic bacteria colony counts after 14 days. Sesame oil exhibited similar effectiveness as
chlorhexidine in reducing plaque-induced gingivitis [25].
A clinico-microbiological study was carried out by Saravanan et al. to assess the effect
of sesame oil pulling on dental plaque, colony-forming bacteria, and gingivitis. The results
of the study stated that the oil pulling group demonstrated significant reduction in plaque
index scores, bacterial counts, and gingival index scores compared to the group that used
only routine oral hygiene methods [26].
In a recent study, the anti-inflammatory effect of coconut oil has been demonstrated
in subjects with plaque-induced gingivitis. The authors reported a significant reduction
in gingival inflammation, which was attributed to the aforementioned antimicrobial and
anti-inflammatory activity, decreased accumulation of plaque, and the emollient effect of
coconut oil with no untoward side effects [2].
10.6.3
Halitosis
Halitosis or bad breath is a common problem that can often cause social embarrassment.
The malodor is produced from volatile sulfide compounds especially dimethyl sulfide,
hydrogen sulfide, and methyl mercaptan, originating from the proteolytic degradation of
the peptides present in food debris, saliva, plaque, and desquamated epithelial cells. Gramnegative proteolytic bacteria responsible for periodontitis and gingivitis are also known to
produce sulfide compounds [5].
Effect of Oil Pulling on Oral Health
149
Asokan and colleagues conducted a randomized controlled study to evaluate the effecacy
of oil pulling in controlling halitosis. Enrolled 20 study subjects were randomized equally
into two groups. In addition to routine oral hygiene practice, group I was advised to perform sesame oil pulling for 10 to 15 min in the morning, while group II was instructed to
use 0.2% chlorhexidine rinse for 1 min in the morning. Five clinical parameters (plaque
index, modified gingival index, self-assessment of breath, organoleptic breath assessment,
and the BANA test) were evaluated at baseline and day 14. At the end of the study, both
groups showed a significant decrease in scores of all parameters. Hence, the authors concluded that oil pulling was as good as chlorhexidine in reducing microorganisms associated
with malodor [27].
In a recent study, an especially formulated oil by Dentiste, Thailand (Dentiste’7M oil),
demonstrated an in vitro inhibitory effect against the prominent VSC-producing bacterium, P. gingivalis. Consequently, swishing with this newly formulated oil may be beneficial
in managing oral malodor [28].
10.6.4
Oral Thrush
Oral thrush or oral candidiasis is a non-contagious fungal infection caused by Candida species. It is commonly seen in individuals taking medications that may alter the oral microflora over extended periods. Denture wearers, patients undergoing prolonged antibiotic
treatment or using inhaled corticosteroid for asthma, and patients undergoing chemotherapy or radiotherapy reportedly have a higher incidence of oral candidiasis.
Evidence suggests that oil pulling therapy improves symptoms of oral thrush in two ways.
First, it traps or pulls the toxins and other pathogens during oil swishing and therefore aids
in the mechanical removal of the pathogens from the oral cavity. Second, the antifungal
properties of the oils used, particularly coconut oil, kills the yeast in the oral cavity and
therefore plays a role in eliminating the candida pathogens [5].
10.6.5
Xerostomia and Burning Mouth Syndrome
Xerostomia is defined as dry mouth resulting from reduced or absent saliva flow. Xerostomia
is not a disorder, but it may be an indicator of some underlying medical illnesses, an adverse
effect of several of medications, or an undesirable effect of a radiation to the head and neck.
Decreased salivary gland function may or may not be associated with xerostomia.
Burning mouth syndrome (BMS) is a condition that is commonly associated with burning sensation and dryness of mouth, altered taste, and mostly affects the women of menopause transition age. Despite the large number of available trials on the management of this
condition, there seems to be no complete cure until date, which is mainly attributed to the
uncertainty of this condition.
In a double-blinded cross-over study, Xerolube (artificial saliva) and vegetable oil were
compared as a treatment for xerostomia in patients with cancer of the head and neck. All
enrolled subjects were randomly allotted to two groups: vegetable oil or Xerolube for a
2-week duration of treatment. After the washout period of 2 weeks, the products were
switched among the groups for another 2 weeks. A 17-item Mouth Dryness Questionnaire
(MDQ) was used to record the participants’ subjective experiences of dryness. Results
revealed significant improvement in non-tobacco users with the utilization of oil and
150 Natural Oral Care in Dental Therapy
emphasized a superior predilection for vegetable oil. The MDQ scores exhibited no significant differences between the two treatments. Hence, the authors concluded that vegetable
oil can be used as an inexpensive and effective substitute treatment modality for patients
with xerostomia induced by radiation [29].
Garg et al. assessed the efficacy of sesame oil pulling therapy in the treatment of patients
suffering from primary BMS. All clinically diagnosed BMS patients were advised to perform
oil pulling once daily for a period of 3 months. The Visual Analog Scale (VAS) was used to
assess symptoms of stomatopyrosis and xerostomia at the end of every month. The results of
the study revealed a significant improvement in the symptoms of both stomatopyrosis and
xerostomia at the end of 3 months follow-up when compared with the baseline status [30].
10.7 Drawbacks of Oil Pulling
The drawbacks associated with the practice of oil pulling are [31];
a. Oil pulling cannot be used as monothearapy.
b. It is a time-consuming procedure.
c. Recently, few isolated case reports have highlighted that improper technique
of oil pulling led to aspirational lipoid pneumonia in patients using this
technique vigorously [32, 33].
Ayurvedic literature has reported possible negative side effects if improper technique
is used, such as dryness of mouth, excessive thirst, dysgeusia, exhaustion, and muscular
stiffness [4].
The first systematic review by Oghenekome Gbinigie at the Centre for Evidence-based
Medicine, University of Oxford, UK, proposes that oil pulling may have advantageous
effects on oral hygiene as observed from short-term investigations [34]. As stated that as oil
pulling is a potentially low-cost therapeutic modality, this procedure might be of particular
benefit. More meticulous long-term clinical trials are required to further evaluate local and
systemic benefits of oil pulling therapy.
References
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17. Shanbhag, V.K., Oil pulling for maintaining oral hygiene—A review. J. Tradit. Complement.
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Dent. Hypotheses, 4, 131–4, 2013.
19. Peedikayil, F.C., Remy, V., John, S., Chandru, T.P., Sreenivasan, P., Bijapur, G.A., Comparison
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11
Role of Proteolytic Enzymes in Dental Care
P. Kalyana Chakravarthy1* and Sravan Kumar Yeturu2
1
Department of Public Health Dentistry, Manipal College of Dental Sciences, Manipal,
Manipal Academy of Higher Education, Manipal, India
2
Department of Public Health Dentistry, Amrita School of Dentistry, Amrita Vishwa Vidyapeetham,
Kochi, India
Abstract
Plant-based proteolytic enzymes include papain, bromelain, actinidin, and ficin. These enzymes
have been tried and tested for numerous applications in the professional as well as personal oral
health care. The range of applications include basic oral hygiene maintenance via dentifrices, as antiinflammatory and adjuvant to antibiotics in postoperative management, possible role in management of cancer and oral mucositis, caries excavation, and increasing bond strength for bonding
orthodontic brackets. Literature pertaining to these areas has been reviewed, and findings have been
discussed with future scope for research.
Keywords: Tooth whitening, plaque, gingivitis, halitosis, papain, bromelain, cancer,
mucositis, caries removal
11.1 Introduction
A strong desire among the consumers for natural products is steadily increasing, and manufacturers are constantly trying to meet these demands of the consumers. Currently, there is
a wide range of herbal products that are targeted for dental care. One such category of products is plant-based proteolytic enzymes, which are mainly proteases. Common plant-based
proteolytic enzymes that are of interest in the field of dentistry are papain and bromelain.
Actinidin and ficin are some emerging newer products that are being researched for their
possible applications in oral health. Many reviews exist in the literature that describe the
potential applications of these products in only the medical field. However, many applications of these enzymes have been researched for use in the field of dentistry (Figure 11.1).
This chapter reviews the literature pertaining to the applications and efficacy of these proteolytic enzymes for professional and personal oral health care.
Papain is a proteolytic enzyme that comes from the latex of the leaves and fruits of the
papaya. It has an anti-inflammatory, bacteriostatic, bactericidal characteristic and is effective against gram-positive and gram-negative organisms [1].
*Corresponding author: drkalyan81@gmail.com
Durgesh Nandini Chauhan, Prabhu Raj Singh, Kamal Shah, and Nagendra Singh Chauhan (eds.)
Natural Oral Care in Dental Therapy, (153–170) © 2020 Scrivener Publishing LLC
153
154 Natural Oral Care in Dental Therapy
Malodour
Gingivitis
Extrinsic Stains
Increased bonding of
Restorations
Control of Biofilm
Plaque
Periodontics
Children
Differently Abled
Less, Pain, Discomfort
and Minimally Invasive
Improved Action of
Antibiotics
Dry Socket
Improved Healing
Post Extraction
Management
Blood Coagulation
and Fibrinolytics
Oral Surgery
Chemomechanical
Caries Removal
Plant based
Proteolytic Enzymes
Post Surgical
Edema
Post Surgical
Ecchymosis
Geriatric Patients
Avulsed Teeth
Anxious and
Phobic Patients
Orthodontics
Removal of Smear
Layer
Less
Microleakage ?
Oral Medicine
Increased Bonding
of Brackets
TMJ Osteoarthritis Antimicrobial
Action
Oral Submucous
Fibrosis ?
Oral Cancer, Oral
Mucositis ?
Figure 8.1 Overview of the potential applications of proteolytic enzymes in the field of dentistry and oral care.
Bromelain is a complex natural mixture “thiol endopeptidases and non-protease components, including phosphatases, glycosidases, peroxidases, cellulases, glycoproteins, ribonuclease, carbohydrates, and others” [2]. It is derived from pineapple, which has numerous
therapeutic applications.
Actinidin or actinidain is an enzyme, which is commonly present in fruits like kiwi,
pinapple, papaya, mango, and banana. Ficin or ficain is a latex derived from the trunk Ficus
insipida. All these enzymes are cysteine proteases.
11.2 Role of Proteolytic Enzymes in Oral Surgery
11.2.1
Post-Extraction Management
Postoperative complications after dental extraction include pain, dry socket, swelling, and
limited mouth opening. Clinical management includes immediate cold and later hot compression, administration of analgesics and antibiotics as per the need. Proteolytic enzymes
act at various sites of receptors on the cell surface that have variable role on the inflammatory components. It was shown that there was improvement in postoperative pain, swelling, and mouth opening and overall quality of life [3]. The possible mechanism of action
suggested was due to the downregulation of inflammatory markers (IL-25 and TNF-α) and
increased expression of EGFR and β-FGF. This led to the proliferation of fibroblasts, endothelial and epithelial cells, epithelization, and neovascularization, which hastened wound
healing. Inchingolo et al. [4] concluded that the efficacy of bromelain is similar to that of
ketoprofen in the reduction of pain and edema. Majid and Al-Mashhadani [5] reported on
the analgesic and anti-inflammatory effects of bromelain, which is comparable to preemptive diclofenac and showed a significant positive effect on the quality of life measures with
only a limited reduction of trismus.
Ghensi et al. [6] evaluated the effect of oral administration of bromelain in postoperative discomfort after third molar surgery. They concluded that there was a 22% reduction
in edema at day 2 compared to the control group. Bromelain showed anti-inflammatory
properties, but the use of dexamethasone was inevitable. It was also suggested that the
Proteolytic Enzymes in Dental Care 155
best results were seen when bromelain and dexamethasone were given in conjunction.
The use of bromelain alone had minimal effect on pain, while the combination of bromelain and dexamethasone showed significant lower consumption of analgesics than the
control group. They also concluded that bromelain had little effect on postoperative trismus. De la Barrera-Núñez et al. [7] assessed pain relief after third molar extraction and
showed that the bromelain and placebo groups were the same in terms of the pain score.
Eslami et al. concluded that oral administration of bromelain showed no effect on pain,
swelling, and trismus after third mandibular molar removal [8]. Singh T et al. [9] concluded that there was overall effectiveness in terms of reduced pain, swelling, and healing
time and also reported that there was effective reduction of pain and swelling in 70% of
their patients. Tassman et al. [10] reported that bromelain was better than the placebo
for the reduction of the degree and duration of edema and pain for 81% of the patients.
Ordesi et al. [11] found a significant reduction in pain and swelling after extraction of
the third molars in patients who have taken bromelain when compared with the controls.
Vigano et al. [12] conducted a prospective and controlled study to evaluate the antiinflammatory and analgesic effect of bromelain with or without paracetamol and codeine
during pre- and postoperative oral surgery (implants, impacted molars, sinus lift, and
enucleation of cysts).
Variations in the findings could be due to the heterogeneity in the dosage of bromelain,
which was used in these studies (150 mg to 1000 mg/day). Other possible mechanisms
of actions reported in the literature were through alteration of pain mediators (bradykinin), inhibiting the synthesis of pro-inflammatory prostaglandins (PGE2), and resolution
of edema due to fibrinolytic action [9].
11.2.2
Post-Surgical Facial Ecchymosis and/or Edema
Seltzer et al. [10] evaluated the effect of bromelain on the resolution of ecchymosis and
edema after rhinoplasty. They found that one to two tablets four times a day had fewer days
of ecchymosis and edema than placebo. Seltzer et al. evaluated the effect of bromelain on
ecchymosis and edema after surgical and nonsurgical facial trauma. They found a significant difference between bromelain and placebo for inhibition of ecchymosis and edema.
Shetty and Mohan [13] evaluated the effect of systematic enzyme therapy on the thickness of soft tissue in bimaxillary orthognathic surgery patients. They found a significant
improvement in the treatment than in the placebo group measured by ultrasound. Woolf
et al. [14] evaluated the effect of bromelain on artificially induced hematoma and found a
significant improvement of edema compared with the placebo. However, Gylling et al. [15]
evaluated edema after facial plastic surgery and found that there was no significant difference between bromelain and control groups.
Bromelain can be of use in wound debridement and removal of necrotic tissues.
Bromelain has been shown to have wound debridement properties by hydrolysis (in vitro
and in vivo) without effecting the normal tissue [2, 16]. Conventional surgical debridement
can be simplified by complementing topical bromelain [2], and it was seen that it alters the
wound microenvironment thus promoting healing. A systematic review on the effect of
bromelain for edema and ecchymosis concluded that bromelain may not be efficacious for
larger procedures [10]. Bromelain administered in multiple doses may have interactions
with food consumption that may affect the absorption and the efficacy of bromelain [10].
156 Natural Oral Care in Dental Therapy
11.2.3
Enhanced Action of Antibiotics
Combined bromelain and antibiotic therapy was effective than only antibiotics in the treatment of cutaneous Staphylococcus infection, cellulitis, and sinusitis [17, 18] and has reduced
the side effects [16]. Shahid et al. [19] evaluated the efficacy and safety of combined oral
dose of bromelain, trypsin, and rutin as an adjuvant therapy in the treatment of sepsis
among children in a double blind randomized controlled trial. The duration for subsiding
fever and need for hemodynamic support were significantly lower in children with adjuvant
therapy than in the placebo group. The study concluded that adjuvant therapy (bromelain,
trypsin, and rutin) with antibiotics and support care was effective in the treatment of sepsis
among children.
11.2.4
Effect of Bromelain on Blood Coagulation and Fibrinolysis
Bromelain showed an effect on serum fibrinolytic ability [47]. Animal studies showed that
higher concentration prolonged prothrombin time, and activated partial thromboplastin
time was seen [48]. Hence, dentists and oral health care providers should be cautious in
prescribing bromelain in subjects with coagulative disorders or those on anticoagulants.
It is recommended that bromelain be administered before food intake, and daily dosage
should be 750–1,000 mg/day in divided doses.
Nevertheless, plant-based proteolytic enzymes have multitude of applications in the field
of oral surgery. Clinicians should consider the benefits and harms in recommending these
enzymes routinely to the patients. Further, high-quality clinical trials are needed to have
high quality evidence to prescribe these enzymes for various applications in the field of oral
surgery.
11.3 Role of Proteolytic Enzymes in Cancer and Oral Mucositis
11.3.1
Cancer
Bromelain can be an alternative effective anticancer agent due to its system involving multiple cellular and molecular targets [20]. However, the exact mechanism of action is not
clearly established. Currently, only literature review exists on their role as an anticancer
agent. Bhui et al. [21] conducted laboratory studies to understand anti-tumor-initiating
potential of bromelain using a tumorigenesis model. It was seen that there was a delay
in initiation of tumorigenesis and increased tumor-free survival, which was linked to the
apoptosis and anti-inflammatory activities. There was a so-called “preventative effect” due
to the reduction of tumor volume (65%). Dhandayuthapani et al. [22] reported on dosedependent cytotoxic effects of bromelain in cell lines (breast cancer). It increased caspasecleaved cytokeratin concentration, which is a marker for apoptosis. In an in vivo study
[23], bromelain inhibited translocation of nuclear factor-κB via G2/M arrest to apoptosis
in epidermoid carcinoma and melanoma cells of humans. It was also seen that there was
selectively induced apoptosis by upregulation by the expression of p53 and initiation of
the mitochondrial apoptotic pathway in tumor cells [24] along with a decreased activity of
cell survival regulators promoting apoptosis leading to cell death of tumor cells [25]. An
ongoing phase II randomized, two-armed clinical study is being performed to evaluate the
Proteolytic Enzymes in Dental Care 157
efficacy of oral high dose versus low dose bromelain (Comosain) in human subjects diagnosed with advanced late stage cancers [26].
Currently, mechanisms were proposed for the applications of these proteolytic enzymes
as treatment modality for cancer. However, clinical research on their role is scant. Future
studies are required and should focus on the clinical effectiveness of these enzymes in the
treatment of head and neck cancers as well.
11.3.2
Management in Oral Mucositis
Mucositis, which is the result of cancer chemotherapy and radiotherapy, can have symptoms like pain, lack of taste function, reduction in food intake leading to weight loss,
treatment delays, dose adjustments, etc. Proteolytic enzymes have been used in the
management of oral mucositis that are a result of chemotherapy and radiotherapy for
the treatment of cancers. Beneficial effect of these proteolytic enzymes could be due to
the anti-inflammatory action, but the mechanism is not clearly understood. Dorr et al.
conducted a randomized placebo-controlled trial to evaluate the effectiveness of Wobe–
Mugos E (mixture of proteolytic enzymes papain, trypsin, and chymotrypsin) to reduce
the oral mucositis after radiotherapy [27]. No beneficial effect of this drug was seen in the
treatment of oral mucositis over placebo. Similarly, a prospective randomized, open study
by Gujral et al. evaluated proteolytic enzymes (Wobe–Mugos E) in conventional radiation therapy for oral mucositis [28]. They concluded that adjuvant enzyme therapy can
have significant protection for radiation-induced side effects. Lower grades of mucositis
scores were also reported by Kaul et al. with the use of pre- and post-radiotherapy proteolytic enzymes [29]. However, Cochrane review on interventions on mucositis reported
a weak evidence [30].
11.4 Osteoarthritis
Osteoarthritis is a chronic degenerative disease of the hard and soft tissues around the
temporomandibular joint. It involves the deterioration of the articular cartilage and synovial tissues and structural changes in bone. It can cause pain and/or dysfunction in functional movements of the jaw, and symptoms can be varied from one patient to another.
Management is usually done by pharmacological (analgesics, anti-inflammatory, steroid
injections) and non-pharmacological methods (hot and cold therapy, strengthening exercises, TENS, Lasers). A combination of bromelain, trypsin, and rutin in osteoarthritis
patients of the knee and shoulder has been studied previously [31]. Not much literature
exists on the role of bromelain on osteoarthritis of TMJ, but the analgesic properties (influence on bradykinin) could be [32] useful to treat osteoarthritis of TMJ. Jayachandran and
Khobre [33] have evaluated the combination of bromelain, trypsin, and rutin with or without diclofenac in the treatment of osteoarthritis of TMJ. Subjects with combination therapy
of enzymes and diclofenac responded better than those subjects with only diclofenac or
enzyme therapy. Very limited research has been conducted to evaluate the effectiveness of
these enzymes in the treatment of osteoarthritis of the temporomandibular joint. Further
high-quality clinical trials are required to evaluate the potential role of these enzymes in the
management of temporomandibular joint osteoarthritis.
158 Natural Oral Care in Dental Therapy
11.5 Anti-Microbial Action
Papain and bromelain have been tested for their efficacy against numerous oral microorganisms in varied laboratory conditions. Silva et al. evaluated the role of bromelain in the
reduction of preformed Candida biofilm biomass and metabolic activity. A total of nine
Candida strains were tested to quantify biomass biofilm formation, and metabolic activity
of sessile cells within the biofilms was measured. There was marked reduction in biofilm
biomass in the majority of strains for the three highest concentrations of bromelain (0.5,
0.25, 0.125 mg/mL) used, while the effect on biofilm cell metabolism was not so evident
[34]. In an in vitro experiment on Candida albicans, Bromelain stimulated phagocytosis
and respiratory burst killing [35].
Bharadwaj et al. [36], in an in vitro study, compared the effectiveness of Morinda citrifolia, papain, aloe vera, 2% chlorhexidine gel, and calcium hydroxide in the control of
Enterococcus faecalis. Results showed that the chlorhexidine gel showed the maximum, and
calcium hydroxide showed the least, effectiveness. Morinda consistently exhibited good
inhibition followed by aloe vera gel and papain gel.
Basting et al. evaluated [37] the antimicrobial effect of papain-based gel followed by
self-etching adhesive systems with and without MDPB monomer on Streptococcus mutans
and Lactobacillus casei. With respect to Streptococcus mutans, papain-based gel followed
by the application of adhesive systems had lower colony-forming units than papain-based
gel only. No significant differences were seen between the two types of adhesive systems.
Results for Lactobacillus casei showed that papain-based gel followed by the application of
adhesive systems had lower colony-forming units than papain-based gel only. However,
the control group was not included in the statistical analysis. On the contrary, Mendez et
al. [38], in an in vitro study, reported that papain did not exhibit growth inhibition, while it
showed increased growth in the liquid medium.
Mota et al. [39] conducted an in vitro antimicrobial evaluation of Eucalyptus globulus, xylitol, papain, and chlorohexidine on Pseudomonas aeruginosa, Samonella sp., Staphylococus
aureus, Proteus vulgaris, Escherichia coli, and Candida albicans. Papain (10%) showed a
lower antimicrobial effect than chlorhexidine in relation to Candida albicans, and further
investigation is recommended. Papain at a concentration of 20% showed no inhibition with
respect to the microorganisms under study.
Praveen et al. [40] tested the minimum inhibitory concentration of bromelain on
Streptococcus mutans, Enterococcus fecalis, Aggregatibacter actinomycetemcomitans, and
Porphyromonas gingivalis. They found that Streptococcus mutans showed sensitivity at a
concentration of 2 mg/ml, Porphyromonas gingivalis at 4.15 mg/ml, while Aggregatibacter
actinomycetemcomitans showed at 16.6 mg/ml and Enterococcus fecalis showed at 31.25 mg/
ml. Bromelain showed its effectiveness on potent periodontal pathogens.
Kulakarni et al. [41] compared the efficacy of papain-based gel (Papacarie) and conventional excavation in reducing cariogenic flora using excavated dentin samples. They
reported similar reductions in cariogenic flora with both the techniques.
Motta et al. [42] conducted a randomized, controlled split-mouth clinical trial to check the
efficacy of papain-based gel and conventional method in reducing the bacterial counts. In both
the groups, there were significant reductions in total bacteria, Streptococcus and Streptococcus
mutans, while no such significant difference was seen with respect to Lactobacillus CFUs.
Proteolytic Enzymes in Dental Care 159
Numerous studies have shown the anti-microbial actions of these enzymes via in vitro
studies. Future research should focus on the effectiveness on biofilm models to corroborate
clinical effectiveness of these enzymes.
11.6 Treatment of Dental Carious Lesions
Carious dentine consists of two different layers. The outer layer (infected dentine) is irreversibly damaged and not remineralizable, which needs to be excavated or removed. The
inner layer (affected dentine) can be remineralizable and can be left behind during the
carious excavation procedures [43].
Conventional carious removal involves [44] the use of rotary instruments, which is
rapid with inherent risks like damage to the sound tooth structure, excess heat generation,
and sensitivity. They may also have noise and vibration, which might increase anxiety in
young children making uncooperative to restorative procedures. An alternative technique
like atraumatic restorative treatment involves the use of hand instruments only. It was also
noticed that caries can be excavated using chemicals that are known as chemomechanical
caries removal. This technique gained popularity in the treatment of carious lesion in anxious children, special children, geriatric patients, and medically compromised patients. It
minimizes patient stress and need for local anesthetic injections [45–47]. Many advantages
for chemomechanical caries removal are reported like viz., selective removal of infected
dentine and atraumatic with antibacterial activity [48]. The principle that an active ingredient acts on the predegraded collagen of the lesion, promoting its softening, without acting
on healthy adjacent tissue and without causing pain, has made this technique an effective
alternative for treatment of carious injuries [1]. It acts by breaking partially degraded collagen fibrils and softens the infected dentin, which then can be removed using blunt hand
instruments. Some commercial preparations like Papacarie and Carie-care, which are based
on papain gel, are now available.
11.6.1
Laboratory Studies
Chittem et al. [49] in an in vitro study compared the microshear bond strength of the
caries-affected dentinal surface after treatment with papain-based gel and conventional
techniques. The time duration was significantly more with papain-based technique than the
conventional technique, which can be mitigated by an experienced user [50]. They reported
that papain-based chemomechanical caries removal techniques are reliable methods for
caries removal with conventional adhesive systems. Similarly, Aly Khattab et al. [51] aimed
to evaluate papain-based gel (Papacarié) on microshear bond strength and microleakage
and of two restorative materials. Composite restoration exhibited less microleakage and
better micro-shear bond strength than glass ionomer cement. Gianini et al. evaluated the
microtensile bond strength of two different adhesive systems to demineralized dentin after
the use of a papain-based chemomechanical method. It was seen that there was no interference in the adhesion due to the use of papain-based gel.
Hafez et al. [52] compared the microleakage of composite restorations after papain-based
chemomechanical caries removal and conventional technique. There was no significant
160 Natural Oral Care in Dental Therapy
difference in the degree of microleakage and the diameters of the resin tags, while a significant thick hybrid layer was seen in papain-based chemomechanical caries removal compared with the conventional technique.
Alhumaid et al. [53] compared the volume of removed tissue and dentin mineral density
after excavation between Carisolv and papain-based gel. Results showed that there was higher
dentin mineral density, more sound dentin, and less removed tissue in the papain group.
Nair et al. [54] compared the microtensile bond strength and chemical composition of
the dentin of teeth after the use of three commercially available chemomechanical caries
removal agents (Carisolv, Papacarie, and Carie-care). No significant difference in the mean
bond strength and calcium–phosphate ratio was observed among the groups studied.
Somani et al. [55] evaluated the efficiency of different chemomechanical caries removal
agents in smear layer removal in an in vitro study using scanning electron microscopy. Smear
layer removal was significantly higher in the sodium hypochlorite-based gel (Carisolv), followed by papain-based gel (Carie-care) with the least being in the control group (saline).
Viral et al. [56], in an in vitro study, compared the efficiency, marginal leakage, and shear
bond strength of Carisolv and Papacarie in primary molars. Papacarie took significantly
less time than Carisolv. Higher proportion of teeth treated with Carisolv did not show any
marginal leakage than Papacarie. The mean shear bond strength of Carisolv was more when
compared to Papacarie. Papacarie was efficient in caries removal but showed more marginal
leakage than Carisolv.
Bittencourt et al. [57] quantified the mineral content removed from primary teeth after
excavation of caries using papain-based gel. The authors concluded that the amount of calcium removed with papain-based gel affected only the carious component of the teeth.
Kotb et al. [58] evaluated the topographic features of dentin after caries removal with
papain-based gel and conventional techniques. Papain-based gel showed irregular, porous,
rough, and globular dentin appearance. Papain-based gel produced partial or complete
removal of the smear layer and with open dentinal tubules in contrast to the conventional
technique.
11.6.2
Clinical Studies
Kitsahawong et al. [59] comprehensively compared the efficacy of Papacarie gel and conventional drilling on various factors like caries removal, time, morphological changes, and
microhardness of surface dentin, and microleakage of subsequent restorations. There was
no difference in the caries removal between groups. The Papacarie group showed significantly longer time for caries removal, more microleakage, and lower dentin hardness than
the drilling group.
Carrillo et al. [60] conducted a randomized controlled open label study to evaluate caries
removal time and patient acceptance of the chemomechanical caries removal agent and
papain gel among disabled children. Papain gel had a completed caries removal time of
8 min per tooth and is well accepted by the patients in all phases and visits of treatment.
Khalek et al. [61] compared pain and discomfort scores (Sound, Eye, and Motor scale)
using Papacarie (papain-based gel) and conventional atraumatic restorative treatment. They
have reported that Papacarie required significantly longer duration of time than atraumatic
restorative treatment. Sound, eye and motor component scores were significantly lower in
the Papacarie than in the atraumatic restorative treatment group. In an adjusted model, it
Proteolytic Enzymes in Dental Care 161
was seen that the method of caries removal had significant effect on sound eye and motor
component scores when adjusted for gender, age in years, arch, tooth, lesion type, and time
to remove caries in minutes. Kotb et al. [62] clinically evaluated Papacarie in the primary
teeth along with the need for local anesthesia, time for removal of caries, and sound, eye,
and motor component scores. They found that the Papacarie group did not required local
anesthesia, while it was required by majority of the participants in the conventional group.
No significant difference was seen with respect to time required to perform the procedure
between Papacarie and the conventional treatment. However, when the time required for
administering local anesthesia was included, conventional procedure required significantly
longer duration than the Papacarie gel. Similarly, sound, eye, and motor component scores
were significantly lower in the Papacarie than in the conventional group.
Konde et al. [50] compared the conventional and chemomechanical caries removal
(papain gel) in primary molars. It was seen that the mean time taken and pain scores in
the conventional method were significantly higher than in the papain gel. However, no
significant difference in the secondary caries rate after a follow-up of 10 months between
the groups.
Matsumoto et al. [63] conducted a randomized clinical split-mouth trial to evaluate the
effectiveness of Papacarie Duo gel in the removal of carious lesions in primary teeth. No
significant differences were seen in terms of time required, pain, or status of the restoration
status after 30 days.
Motta et al. [64] compared the effectiveness of papain-based gel for the chemomechanical removal of carious lesions on primary teeth with regard to time, clinical aspects, and
radiographic findings in a randomized controlled clinical split-mouth trial. No significant
differences were seen between the groups regarding the time required and the radiographic
follow-up. Authors concluded that papain-based gel was effective in carious removal of
deciduous teeth.
Laboratory studies using papain-based gel showed acceptable results with respect to
bond strength, microleakage, mineral content, and smear layer removal. Most clinical studies have evaluated the time taken to perform the procedure, restoration status, and need
for local anesthetics. Comparable results have been reported by papain-based gel in the
treatment of carious lesions in primary and permanent teeth among children and adults.
Papain-based gel can be a suitable alternative caries removal agent that preserves dentinal
tissue. However, this technique of application is limited to cavitated carious lesions, which
are accessible to the hand instruments, and the cavities do not comply with the required
retention form and largely rely on the chemical bond of the restorative materials [59]. The
loosely attached debris and smear layers with high organic content might interfere with
the bonding ability of the restorative materials leading to microleakage. Further clinical
studies are required to evaluate the retention rates of the different restorations after the use
of papain-based gels. A recent meta-analysis also concluded that subsequent caries rate
should also be evaluated as an outcome in future studies [65].
11.7 Improvement in Bonding of Orthodontics Brackets
Enamel etching with phosphoric acid is the preliminary step before the application of a
bonding agent to bond orthodontic brackets. However, it was seen that ideal etching pattern
162 Natural Oral Care in Dental Therapy
may not be attained on the entire surface of the enamel. It is attributed to the outer organic
layer resulting in inconsistent and unreliable enamel surface for bonding. To overcome this
problem, deproteinization of enamel surface was suggested with sodium hypochlorite prior
to the bonding. Pithon et al. [66] reported that 10% papain gel can be an effective enamel
deproteinizing agent by increasing the shear bond strength of the orthodontic brackets irrespective of the etching agent. In another study, Pithon et al. [67] evaluated various concentrations of papain gel (2%, 4%, 6%, 8%, and 10%). They found that 8% and 10% papain gel
showed higher shear bond strength than the control group. Pithon et al. [68], in an in vitro
study using bovine enamel, evaluated shear bond strength with different concentrations of
bromelain in association with 10% papain. Results showed that 3% and 6% bromelain gel in
combination with papain significantly increased the shear bond strength with acid etching
followed by primer application and attachment using Transbond XT and without etching in
resin modified glass ionomer cements.
Agarwal et al. [69] studied the influence of application of Papacarie and indigenously
prepared 10% papain gel as a deproteinizing agent on the shear bond strength of the orthodontic brackets before and after acid etching with phosphoric acid. They reported that
both papacarie and indigenously prepared 10% papain gel when used before acid etching
showed significantly higher shear bond strength than only the acid etching group. Also,
they reported that no significant difference was seen when Papacarie and indigenously prepared 10% papain gel were used after acid etching with only the acid etching group. A
similar trend in the findings was seen with the scanning electron microscope imaging of
the enamel surface. The study also concluded that Papacarie and 10% papain gel before acid
etching increases the types I–II etching patterns.
Hasija et al. [70] reported on the deproteinizing effect of papain and bromelain after
acid etching. Deproteinizing agents like papain and bromelain gel were applied for 60 s and
rinsed and compared with the control and sodium hypochlorite groups in primary teeth.
The authors concluded that shear bond strength was not affected significantly. The bromelain group showed higher mean shear bond strength than the other groups; however, the
difference was not statistically significant.
Dayem and Tameesh [71] evaluated the deproteinizing effect of bromelain enzyme and
compared it with laser (Nd:YAG) and 10% sodium hypochlorite using Scanning Electron
Microscope and polarized microscope. Bromelain was applied for 60 s after acid etching
and was rinsed with distilled water. Bromelain enzyme removed collagen network and significantly reduced the global leakage scores. Chauhan et al. [72] assess the deproteinizing
effect of bromelain enzyme on shear bond strength before the application of the adhesive
system. Teeth were etched with 37% phosphoric acid for 15 s, rinsed with water, blot dried,
and deproteinized with bromelain enzyme. The bromelain enzyme-treated group showed
the highest bond strength compared with the control group.
Zakarea et al. [73] evaluated the removal of a smear layer by a combination of castor
and papain in the root canals. They found that partial removal of both organic and inorganic parts of the smear layer was seen at the middle, apical, and coronal parts of the root.
However, the apical was significantly less clean than the middle and coronal parts.
To conclude, studies conducted on the deproteinizing effect of proteolytic enzymes were
in vitro studies and may not represent the complex clinical failure mechanism involved in
real-life situations. Hence, the results have to be interpreted with caution and have to be
Proteolytic Enzymes in Dental Care 163
correlated with clinical performance. Further, clinical trials are recommended to evaluate
the bonding failure with the use of these techniques.
11.8
Role on Biofilm Control (Plaque, Gingivitis, and Oral Malodor)
Dental plaque is a biofilm on the tooth surface, which is one of the chief causal agents
responsible for two of the most common diseases (dental caries and gingivitis). Yao et al.
[74] studied the effect of various pH values, ionic strength, and temperature on papain
hydrolysis of salivary film. The authors concluded that the key aspects in the hydrolysis of
salivary film were the hydrophobic and electrostatic interactions and hydrogen bonding.
Further, the actions can be enhanced by modifying the pH, ionic strength, and temperature.
Tadikonda et al. evaluated the anti-plaque and anti-gingivitis effect of papain-, bromelain-,
miswak-, and neem-containing dentifrice among orthodontic patients. It was reported that
the mean plaque and gingivitis were lower in papain- and bromelain-containing dentifrice
than in the control group after adjusting for baseline values.
Mugita et al. [75] conducted a double-blind, crossover, placebo-controlled study to evaluate the role of actinidin (cysteine protease derived from the kiwi fruit) on tongue coating removal. There was a higher reduction in the tongue coating for subjects taking the
test tablets (actinidin) compared those taking placebo in both young and elderly subjects.
Significant difference in the tongue coating was observed only in the elderly, but not in the
young adults, with respect to baseline. Mugita et al. evaluated the in vitro effects of proteases
(papain, actinidin, trypsin) on oral bacterial biofilm detachment on the tongue (monospecies biofilm). Papain reduced Actinomyces biofilms completely at 10 mg/mL after an
incubation of 60 s and at 1 mg/mL after an incubation of 30 min. Dose-dependent removal
of biofilm was seen with actinidin similar to papain. Similarly, in a later investigation on
multispecies biofilm, actinidin, papain, and trypsin fully disrupted multispecies biofilms at
a high concentration at the end of 60 min. These enzymes even inhibited the formation of
the multispecies biofilms.
Nohno et al. [76] evaluated the long-term use of candy tablets containing protease,
actinidin tongue coating, and volatile sulfur compounds (double-blind randomized crossover trial). Measurements of volatile sulfur compounds significantly decreased only in the
test group at the end of 7 days. However, no such difference was seen with respect to tongue
coating.
Yoshimatsu et al. [77] investigated the effect actinidin on the reduction of human tongue
coating (crossover studies and double blind experiments) and observed that protease tablets
were effective in biochemical cleaning of the tongue. Later [78], they investigated the effects
of the same on the concentrations of volatile sulfur compounds in human mouth air. There
was significant reduction in the concentrations of hydrogen sulfide, methylmercaptan, and
total volatile sulfur compounds with the use of protease tablets at 90 min after administration, while no change in volatile sulfur compounds was seen in the placebo group.
Sugimoto et al. [79] evaluated the surface roughness and actinidin enzyme tablet on the
reduction of tongue coating (number of bacteria). The number of bacteria on the tongue
was significantly reduced in the enzyme compared to the non-enzyme group. However, no
difference was seen when the roughness of the tablet was taken into consideration.
164 Natural Oral Care in Dental Therapy
Clinical studies conducted so far have evaluated the effectiveness of plaque, gingivitis,
halitosis, and tongue coating. They showed effectiveness of these proteolytic enzymes and
can be suitable alternatives in maintaining oral health. Nevertheless, further clinical trials
are needed in diverse populations to gather more evidence on the effectiveness and also to
monitor the adverse effects related to the use of these products.
11.9 Extrinsic Stain Removal on the Teeth
Stain removal of toothpaste is mainly related to the abrasive content of the toothpaste. The mechanism of action of whitening toothpastes is by disrupting or removing the protein portion of the pellicle/plaque layer on the tooth surface. Kalyana et
al. conducted an in vitro study to evaluate the stain removal efficacy of papain- and
bromelain-containing toothpaste [80]. The mean lightness value after the brushing regimen was significantly higher for papain and bromelain toothpaste than the control
group. Lyon Jr et al. [81] also evaluated Citroxain (mixture of papaya, alumina, and
sodium citrate)-containing toothpaste and found similar results. Similarly, Munchow
et al. [82] evaluated bromelain- and papain-based gels and found that they are effective in bleaching stained dental enamel. However, efficacy was lower than that of the
carbamide peroxide group. Yao et al. [83] evaluated the potential of cysteine proteases
(papain, stem bromelain, and ficin) on protein pigment removal. They concluded that
effective elimination of theoflavin bound to dephosphorylated bovine β-casein was by
hydrolyzing target substrates and preventing theoflavin readsorption after hydrolysis.
Vejai Vekaash et al. [84], in an in vitro study, evaluated different concentrations of
hydrogen peroxide-containing pineapple extract as an additive. Specimens bleached
with pineapple extracts along with different concentrations of hydrogen peroxide (10%,
20%, and 30%) showed statistically significant whitening when compared to the specimens that were bleached only with hydrogen peroxide (10%, 20%, and 30%). Also, a
20-min protocol showed significantly higher color change than a 10-min protocol at
all concentrations of hydrogen peroxide with pineapple extracts. However, no significant difference was seen among 10%, 20%, and 30% hydrogen peroxide with pineapple
groups with respect to the color change.
Chakravarthy and Acharya [85] evaluated the clinical stain removal efficacy of papain
and bromelain toothpaste. They showed that papain and bromelain dentifrice showed significant stain removal when compared to the control and attributed this to papain and
bromelain. Patil et al. [86] conducted a randomized, triple blind, parallel group study to
evaluate the effectiveness of abrasive and enzymatic (papain and bromelain) whitening
toothpastes. They showed that both the toothpastes were effective in the removal of extrinsic stains, and papain- and bromelain-based toothpaste showed better results compared to
abrasive toothpaste.
The summary of in vitro and clinical studies suggests the effectiveness of these proteolytic enzyme-based dentifrices in stain removal. These products can be suitable alternatives
without having secondary complications seen with the use of conventional teeth whitening
products. More studies are needed to reinforce the evidence on this effectiveness and also
on the effectiveness in preventing the stain formation.
Proteolytic Enzymes in Dental Care 165
11.10 Role in Replantation of the Avulsed Tooth
Santos [87] studied the repair process in teeth of rats by delayed replantation after root surface treatment with the papain and sodium fluoride. Teeth were immersed in 50% papain
solution for 20 min followed by immersion in 2% acidulated phosphate fluoride for 20 min.
The results showed that this protocol can be a viable alternate option, but research is lacking
in this area.
11.11 Effect of Bromelain on Immunogenicity
Bromelain can be a potential alternative and adjuvant in the treatment of many chronic
conditions [32]. Many in vitro studies showed the ability of bromelain to modulate surface
adhesion molecules on various cells (T cells, macrophages, natural killer cells) and also
induce the secretion of many mediators of biologic response by peripheral blood mononuclear cells [32].
Mansfield et al. [88] evaluated 500 allergy clinic patients who were prick skin tested with
papain and many common aeroallergens. Among the seasonal allergic disease patients (n =
475), only five had positive skin tests to both papain and local pollens. Among the individuals with negative skin test (n = 25) to pollens, none had skin reactivity to papain. It was seen
that all the papain-sensitive individuals have papain-specific IgE, but none in the controls.
A total of 1.05% of allergic patients had papain sensitivity and also had cross-reacting antibodies with chymopapain. Literature reports that bromelain has very low toxicity. However,
IgE-mediated hypersensitivity reactions cannot be ignored.
11.12 Other Possible Applications and Scope for Future Research
Considering the broad scope and effectiveness of these plant-based proteolytic enzymes,
further scope for research and development can be sought in areas like denture plaque
removal and hygiene maintenance, inhibition of calculus formation, development of oral
rinses, maintenance of toothbrush hygiene, management of dry socket after extraction,
osteoradionecrosis, and management of oral submucous fibrosis. Future research should
also address the possible adverse events, cost effectiveness, patient reported outcomes, and
oral health-related quality of life in view of the current benefits.
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168 Natural Oral Care in Dental Therapy
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12
The Effect of Probiotics on Oral Health
Patricia Nadelman1, Marcela Baraúna Magno1, Mariana Farias da Cruz1,
Adriano Gomes da Cruz2, Matheus Melo Pithon3, Andréa Fonseca-Gonçalves1
and Lucianne Cople Maia1*
1
Department of Pediatric Dentistry and Orthodontics, School of Dentistry, Universidade Federal do
Rio de Janeiro (UFRJ), Rio de Janeiro, Brazil
2
Department of Food, Federal Institute of Education Science and Technology of Rio de Janeiro,
Rio de Janeiro, Brazil
3
Department of Health, School of Dentistry, Universidade Estadual do Sudoeste da Bahia (UESB),
Bahia, Brazil
Abstract
The oral microbiome is a natural community of microorganisms that reside in different areas.
Behavioral aspects of the host can impact this microbiome, destabilize it, and develop disorders.
This last situation is called dysbiosis. Most prevalent oral dysbiosis biofilm-related include caries, gingivitis, periodontal and peri-implant diseases, and candidiasis. Additionally, halitosis is
another oral condition related to a bacterial instability manifested in the tongue or other mouth
sites. Hence, probiotic bacteria have been used to reestablish the microbiotas’ equilibrium.
Concerning the oral environment, the common probiotic strains used are from Lactobacillus and
Bifidobacterium genera, which can be administrated in different presentation forms (lozenge, tablets, powders, gums) and vehicles, including beverages (milks, yogurts, juices) and foods (cheese,
kefir, ice cream, and chocolates bars). The use of these products with probiotics demonstrated
optimistic results as an auxiliary method on the prevention and treatment of oral dysbiosis due to
their direct and indirect effects against the pathogenic oral microorganisms growth and immunomodulation. In this sense, the present chapter aims to present an updated viewpoint of the probiotic effects on oral health, describing the relationship between the administration/consumption
of these bacteria and the main oral dysbiosis, the oral microbiota parameters, and the immune
salivary components.
Keywords: Probiotics, dental caries, gingivitis, periodontitis, candidiasis, halitosis, oral health,
dentistry
12.1 Introduction
Probiotics are defined as microorganisms safe for human consumption that when ingested
in sufficient quantities, result in beneficial effects on individual health [1]. These advantages
*Corresponding author: rorefa@terra.com.br; maia_lc@ufrj.br
Durgesh Nandini Chauhan, Prabhu Raj Singh, Kamal Shah, and Nagendra Singh Chauhan (eds.)
Natural Oral Care in Dental Therapy, (171–196) © 2020 Scrivener Publishing LLC
171
172 Natural Oral Care in Dental Therapy
come from their capacity of inactivate toxins and their receptors, to provide bioactive or
regulatory metabolites, produce bacteriocins that inhibit pathogenic bacteria, modify the
environment, and compete with other microorganisms for adhesion sites and/or nutrients,
preventing colonization by other microorganisms [2–7]. Thus, probiotics can inhibit pathogens and influence the host’s adaptive immune response [8, 9].
In this sense, new approaches to prevent and control oral diseases through the probiotics
inhibitory effect on the progression of pathogens have been developed [6]. This could be a
supporting strategy since the oral cavity has a large microflora, including microorganisms
that cause disorders such as dental caries, gingivitis, periodontitis, candidiasis, and halitosis
[10]. Moreover, saliva has immunological components that can be modulated by probiotics
[11, 12]. Considering that differences between the intrinsic quality of saliva and individual
oral environment vary based on eating habits, probiotics have been used for prophylactic
and therapeutic goals [13–20].
There are several vehicles for probiotic administration including capsules, lozenges,
chewing gum, powder, drinks such as juice, tea, and kombucha, and foods such as cheese,
ice cream, and kefir [21]. The probiotics most frequently used for the oral environment
are from the genera Lactobacillus and Bifidobacterium [22]. Considering the controversies
about the effect of probiotics on oral health, discussing the issue is extremely necessary for
finding scientific evidence about the subject.
In this regard, the present chapter aims to update and discuss the scientific evidence
available in the literature about the probiotic effects on oral health, describing the relationship between the administration/consumption of these bacteria and the main oral dysbiosis
in the oral cavity, and the oral microbiota parameters.
12.2 Overview of Oral Communities and Probiotic-Based
Therapy to Oral Dysbiosis
The human microbiome is described as a natural community of different types of microorganisms, resident of the different compartments of the human body, together with its gene
set [23]. Microbial communities of the body’s endogenous system participate in several
essential functions for human health. Thus, changes in the composition of the microbiome
could significantly affect the normal functions of the body. So, the dynamic microbiome–
host relationship should be considered jointly for health maintenance and disease prevention. The highest microbial diversity is observed in the gastrointestinal tract and in the oral
cavity [23].
Bacteria, fungi, archaea, and viruses are the microbial species that form the oral microbiome. They coexist in structured arrangements in the sites of the mouth [24]. Even the
pathogenic microorganisms are also found in healthy individuals, however, in lower levels
[25]. The behavioral aspects of the host can increase the number of pathogens, influencing
this microbiome, unbalancing it, and developing disorders [24]. This imbalance is called
dysbiosis, which orally can be characterized as a manifestation of pathogens that can grow
the biofilm-dependent disorders [26].
Probiotic and Oral Health 173
This oral biofilm, in its turn, is described as a varied microscopic community located
on the oral surfaces, surrounded in a matrix of polymers originating from microbial
(Figure 12.1) and host [27], and oral microorganisms always form dental biofilm
on tooth [28]. If, on one hand, this microbial organization can be found even without the disease [29], on the other hand, its accumulation may be accompanied by a
change in bacterial composition, and it is the main cause for the initiation and progression of most oral dysbiosis, such as dental caries, gingivitis, periodontitis, and
candidiasis [29, 30].
Regarding oral dysbiosis, oral candidiasis is an infection caused by commensal and
opportunistic fungi belonging to the genus Candida. The species most commonly associated with this condition is Candida albicans—a natural inhabitant of the oral cavity [31].
Similarly to oral candidiasis, gingivitis and periodontitis are also caused by a group of
(a)
(b)
(c)
Figure 12.1 Scanning Electron Microscopy images of oral biofilm. (a) Cariogenic biofilm formed by
S. mutans, S. paranguinis, S. salivarius. (b and c) Cariogenic biofilm + probiotic strains.
174 Natural Oral Care in Dental Therapy
bacteria normally present in the oral biofilm [32]. However, in the periodontal diseases,
the major pathogens are Aggregatibacter actinomycetemcomitans, Porphyromonas gingivalis, Treponema denticola, and Tannerella forsythia [33]. However, only the presence of the
microorganisms is not enough to cause these dysbioses, since they require conditions that
compromise the host’s immune response, resulting in an imbalance of the biofilm’s microorganisms [34, 35].
Another example of an oral dysbiosis is dental caries, which is defined as a biofilm–
sugar–dependent disease [36]. Regarding this disorder, it is known that this microbial
imbalance has a predominance of gram-positive acidogenic and aciduric bacteria [37].
Similar to other diseases, biofilm accumulation is not enough for the progression of carious lesions. In this case, sugars are the fundamental negative factors for their development [38]. After the intake of sugar, sucrose-dependent microorganisms ferment the
available substrate, generate acids, and, subsequently, decrease the biofilm pH [36]. This
acidity not only causes dental demineralization but also selects the more cariogenic bacteria in the biofilm [39].
This association between the microbial communities and the oral cavity has been a subject of growing interest in science in order to develop therapies that can reestablish the
healthy microbiota in individuals with those disorders. Therefore, new methods for preventing and restoring the balance of microbiota from the use of other microorganisms have
been developed. Among these strategies using living cells as preventive and therapeutic
agents, we highlight the use of probiotic bacteria [24].
Their effects are related to the ability to prevent the colonization by other microorganisms through competition with pathogens, reducing their adhesion to the oral surfaces,
antagonizing its effects, inactivating biofilm microbial toxins, or modulating the host’s
immune response [40]. As a result of the successful use of probiotics in the control of gastrointestinal tract balance [41, 42], these microorganisms have been tested in experiments
in the oral cavity.
In order to perform a beneficial effect in the mouth, the probiotic bacteria must have
the ability of adhesion to mucosal or oral epithelial cells, becoming part of the biofilm
[43]. In this sense, the ingestion of probiotics could be one of the possible strategies for
the prevention and therapy of biofilm-dependent diseases [40], since they could interact
with oral microorganisms [44] that cause dental caries, gingivitis, periodontitis, and candidiasis [10].
Among the probiotic strains, species from the genera Lactobacillus and Bifidobacterium
spp. are the most recommended for human use due to its capacity of adhesion and colonization in the surfaces of the oral cavity [45]. The species can be used in association with
other probiotic microorganisms [46] or as the only present probiotic microorganism in the
vehicle [47].
Because of these positive effects, these bacteria have been supplemented in several foods,
drinks, lozenges, and tablets [48], which are considered vehicles for their administration
[49]. There are a wide variety of delivery vehicles including dairy products (milk, yogurt,
curd, cheese, ice cream, kefir), food supplement, juices, tea, kombucha, chewing gum, powder, mouth-rinse, tablets, capsules, and lozenges [50].
Although they have potential benefits, there are still doubts and controversies about the
exact mechanism of action and effect of these probiotic bacteria on the oral microorganisms and their main dysbiosis [51].
Probiotic and Oral Health 175
12.3 Probiotics Mechanisms of Action
The probiotic mechanism of action is still poorly understood, but several studies have
demonstrated results of possible probiotic modes of action [52]. According to Collins &
Gibson [53], an effective probiotic product should be free of pathogenicity and toxicity,
must contain an adequate number of viable cells, remain viable during storage, be detected
in the host, and provoke beneficial effect.
However, the mechanisms of action of probiotics could be resumed in three forms, proposed by Oelschlaege [54] and Busanello [55]: (i) antimicrobial action of products resulted
from microbial metabolism, such as toxins, metabolites, and enzymes; (ii) competitive
exclusion by nutrients and colonization sites; and (iii) immunomodulation of the innate
and adaptive host immune system (Table 12.1).
(i)
Antimicrobial action of products resulted from microbial metabolism
Some probiotics have the ability to suppress the growth of pathogenic bacteria producing bacteriocins that have broad spectrum [52]. According to
Petri [56], probiotic bacteria can release organic acid compounds such as
lactic acid, propionic acid, and hydrogen peroxide, which have antibacterial
effects against pathogenic microorganisms—it creates a hostile environment
for the pathogens. The author also reports that besides the biological effect,
probiotics have also a chemical effect, since the acid’s production reduces the
environment pH, interfering in the metabolism of pathogenic bacteria.
In the oral microbiota, the pH reduction and the changes in the proteic
composition of the salivary film transform the ecosystem, making adhesion
difficult and reducing the number of pathogens in the formation of dental
biofilm [2].
Table 12.1 Possible mechanisms of action of probiotics.
Mechanism of action/effect
Description
(i)
Antimicrobial action of
products resulted from
microbial metabolism
(direct effect against
bacteria)
• Release of organic and inorganic acid compounds
with consequent reduction of the medium pH
• Creation of a hostile environment for the pathogenic
bacteria and action on its cellular metabolism
• Inactivation of biofilm microbial toxins and their
receptors
(ii)
Competitive exclusion by
nutrients and fixation sites
(indirect effect against
bacteria)
Competition with pathogens for nutrients and for
adhesion through obliteration to the cell fixation sites
of the host, forming a physical barrier and preventing
the pathogens adhesion, besides the release of
mucous secretion
(iii)
Immunomodulation of
the innate and adaptive
immune system of the host
Products of cellular metabolism generate
immunomodulation or immunoregulation through
alteration of cytokine and chemokines profiles, and
activation of immune system cells
176 Natural Oral Care in Dental Therapy
(ii) Competitive exclusion by nutrients and fixation sites
Pathogenic microorganisms challenge the symbiotic relationship between
host and normal flora. However, for the pathogenic colonization, free receptor sites—polysaccharide molecules—for its, adhesion must exist in the host
cell wall [57].
When probiotic products are added to the host diet, these beneficial microorganisms adhere to the fixation sites, creating a physical barrier and decreasing the nutrients’ suppression for the pathogenic bacteria, and then probiotic
bacteria can stop the pathogen colonization [55]. Another probiotic mechanism to prevent pathogen adhesion to the host is the secretion of a mucosal
coverage that obliterates the binding sites [57].
In the oral microbiota, probiotics can alter the composition of the oral
biofilm by colonizing microbial biofilms, co-aggregating and competing with pathogenic bacteria, subsequently substituting or reducing their
numbers [5].
(iii) Immunomodulation of the innate and adaptive immune system of the host
Probiotics alter the host’s immune system through two mechanisms: immunomodulation and immunoregulation [58]. Interferences of the immune system may occur through the products of the probiotic metabolism [54], which
are characterized by the alteration of the cytokine, chemokine, and immune
system cells involved in this process [58].
Immunostimulatory probiotics are able to interfere against cancer cells
and infection, inducing the production of IL-12 that activates NK cells and
develops T1 cells. Probiotic bacteria have also an effect against allergy, balancing T1 and T2 cells. On the other hand, immunoregulatory probiotics
were characterized by the production of IL-10 and Treg cells that can also
result in a reduction of allergies, autoimmune diseases, and inflammatory
responses [58].
According to Oelschlaeger [54], the adhesion of probiotics to host epithelial
cells triggers a signaling cascade that leads to immunomodulation through
its contact, where an anti-inflammatory effect occurs, which is often a consequence of the IL-10 expression increase.
12.4 Dental Caries
12.4.1
Definition and Etiopathology
Caries is a disorder characterized by the demineralization of the tooth surface caused after
the production of acid resulting from the microbial fermentation of sugars [59]. Its etiological factors are mainly associated with the diet, hygiene, and microbiota [60].
Historically, dental caries has been defined as a multifactorial disease, depending on
at least three essential factors: (i) the host, represented by the individual and his/her
components such as the oral cavity, teeth, salivary flow, oral hygiene habits, etc; (ii) the
microbiota, represented by the oral microorganisms; and (iii) the substrate, represented
Probiotic and Oral Health 177
by the individual’s diet, characterized by frequency of consumption of fermented
carbohydrates—mainly sucrose, which is the most cariogenic [61].
Nowadays, dental caries is considered a dysbiosis and can be defined as a biofilm–sugardependent disease [28] that affects both temporary and permanent teeth. In summary, the
resident oral microorganisms form biofilms on teeth, fermenting the available sugars, produce acid from this fermentation and, the acidic products create localized demineralization
of dental hard tissues [28].
This cariogenic biofilm is enriched by a large variety of acidogenic/aciduric microorganisms, including S. mutans, S. sobrinus, and species of Lactobacillus, Actinomyces, Atopobium,
Bifidobacterium, Propionibacterium, and Scardovia [24].
The species involved in the caries process have the ability to (i) rapidly make acid from
dietary carbohydrates, being considered acidogenic microorganisms; (ii) they have the
capacity to tolerate low pH, being also considered aciduric microorganisms; and (iii) to have
the ability to produce extracellular and intracellular polysaccharides, which leads to the
adherence to dental surfaces and serve as a nutrient reserve, respectively [62]. Additionally,
these cariogenic bacteria can (iv) compete successfully versus other oral microorganisms
through an increase in its defenses against oxidative stress and its resistance to acid metabolites [63].
However, biofilm accumulation alone is not enough for caries lesion progression. In this
process, sugars are fundamental for disease progression [38]. When sugar is ingested, oral
sucrose-dependent microorganisms ferment the available substrates and produce acids.
From this process, the biofilm fluid’s pH decreases to around pH 5.0 or below [36]. This
acidic pH product also does a selection of the most cariogenic bacteria in the biofilm [39].
These factors contribute to the beginning and progression of dental caries, since the acidic
oral environment caused by bacteria fermentation disturbs the Ca2+, (PO4)3−, and F−. The
decrease in the pH and the increase in the concentration of these ions are serious problems
in the loss and gain of minerals in the oral environment. The acid from sucrose fermentation binds to the Ca2+ and (PO4)3− causing dental demineralization, and consequently, a
caries lesion develops [64].
Dietary fermentable sugars are known as primary factors responsible for modifications in the tooth biofilm [65, 66]. Comparing to glucose and fructose, sucrose is highlighted as the most cariogenic because microorganisms can easily ferment it into acids,
and it has the ability to change the biofilm environment, making it more cariogenic
[67]. Carbohydrate consumption stimulates the proliferation of S. mutans, S. sobrinus,
and Lactobacillus [68, 69]. These bacteria catabolize dietary sucrose and convert it into
polysaccharides. Many of the polysaccharides are hydrolyzed and subsequently used
for growth during periods when there are no readily fermentable dietary carbohydrates
available [70].
Clinically, the development of caries lesions in a healthy patient (Figure 12.2a) initiates
with biofilm accumulation (Figure 12.2b), which is not removed and develops caries signs
that may be presented in two forms: (i) the early stage characterized by active white spot
lesions (non-cavitated lesions with enamel mineral loss) (Figure 12.2c) [71]; and (ii) its progression; when initial lesions are not controlled, it turns into advanced stages characterized
by cavitated lesions (lesions with mineral and structural loss reaching enamel, dentin, or
cementum) (Figure 12.2d and e) [72].
178 Natural Oral Care in Dental Therapy
(a)
(b)
(c)
(d)
(e)
Figure 12.2 Development of caries lesion without treatment. (a) Healthy oral cavity without biofilm
accumulation. (b) Oral cavity with poor hygiene and biofilm accumulation. (c) Oral cavity with early caries
lesions (white spot lesions). (d) Oral cavity with cavitated caries lesions. (e) Oral cavity with dental destruction
by caries lesions.
Therefore, caries prevention is not a simple removal of microorganisms or an improvement in dental resistance. Prevention of complex disorders such as dental caries is directly
related to biofilm control, eliminating residual food and microorganisms [36]. A physiologic
equilibrium of the oral environment controls the caries development through mechanical
methods of biofilm control (brushing teeth and using dental floss) and dietary monitoring
(smart consumption of the sugar, decreasing its ingestion’s frequency) [67].
Despite all these scientific conceptions of patient protection against dental caries, it is
known that certain individuals need more supervising than others to avoid caries lesion
progression. Therefore, dental new approaches to improve oral health, aiming at inflammatory modulating effects, and reducing the amount of biofilm or microorganisms, have been
developed and researched [24], and are still welcome.
Probiotic and Oral Health 179
12.4.2
Probiotics and Dental Caries
To limit or prevent dental caries, probiotics should be capable to compete with pathogens
for nutrients and for adhesion, being part of the biofilm and forming a physical barrier to
avoid the adhesion of pathogenic microorganisms [5, 55, 57]. Consequently, it prevents the
pathogens’ proliferation and institutes a healthy oral colonization [33]. Additionally, some
probiotics can also change the cariogenicity of S. mutans when they are in coexistence [73].
Another probiotics effect on the prevention and control of dental caries could be the
antibacterial action of products resulting from microbial metabolism through bacterial
coaggregation—the aggregation relationship between microorganisms of the same species
or between different species, favoring their adhesion on the dental surface. Some probiotics
strains were tested on an in vitro study and showed the capacity of coaggregate with oral
microorganisms. Among these probiotic bacteria, L. acidophilus mostly coaggregated compared to the others [74].
Considering the crucial function of S. mutans and Lactobacillus in the caries process,
several experiments have been done trying to disturb its cariogenic properties [22]. Several
randomized clinical trials have been performed testing the probiotic administration to
reduce cariogenic bacteria counts in saliva or plaque [75]. First of all, in vitro studies have
shown the capacity of probiotics in the suppression and decrease of S. mutans, Lactobacillus,
and other cariogenic bacteria [76–78]. After that, clinical reports were performed aiming to
improve the evidences [75]. This anti-cariogenic effect may be associated with the probiotics capacity to create a hostile environment for the pathogenic bacteria, which specifically
prevents the adherence of S. mutans [37].
Therefore, the use of probiotics with the target of conserving or renovating the biological environment against the pathogen proliferation associated with the development of the
major oral dysbiosis. Several studies have already evaluated the effect of probiotics in dental
caries using diverse probiotic strains: L. rhamnosus GG [79–81], L. paracasei [82], L. reuteri
[83], Bifidobacterium spp., among others. The microorganisms’ effect was mainly evaluated
on S. mutans and Lactobacillus count in saliva and/or plaque, pH values, and treatment of
root caries lesions [40].
Researches on probiotic strains are still being carried out to recognize the strains that
can perform a positive role against S. mutans and other cariogenic bacteria. Despite the fact
that several studies are already demonstrating the influence of probiotic against the growth
of cariogenic microorganisms, the results cannot be extrapolated because there is no standardization of probiotic strains and administration vehicles [37].
12.4.3
Probiotic-Contained Dairy Products and Dental Caries
Regarding the ingestion of dairy products as vehicles, it should be safe for uninterrupted daily
consumption and suitable for all ages [84, 85]. Dairy products are interesting since they are
not only nutritious foods but because of their natural content of proteins, fats, vitamins, and
minerals (casein, calcium, and phosphate) [86]. The use of probiotics in dairy products could
be considered an auxiliary method to control oral diseases [87, 88], since these bacteria can
neutralize the acid conditions and interfere in the pathogenic species [33].
Therefore, studies have been carried out testing the oral effect of probiotics contained in
dairy products [89]. It has already been reported that cheese prevents enamel mineral loss
180 Natural Oral Care in Dental Therapy
and also helps in its remineralization [90]. Either probiotic ice cream has demonstrated a
positive effect in reducing significantly the levels of S. mutans compared to control products
[85, 91].
Additionally, yogurt is considered as a potential carrier of probiotics and has shown that
it can impact the potential and colonization of the oral biofilm [74] by demonstrating good
effects on reducing the S. mutans count [92, 93], as well as kefir drink [94] and curd [95]
containing probiotics, which also exhibited good results in reduction of salivary bacteria
counts and thus can be exploited for the prevention of enamel demineralization as a longterm resource keeping in mind its cost-effectiveness [95].
Regarding plain milk containing probiotics, studies reveal promising results aiming
at the prevention, control, and treatment of dental caries. Milk containing L. rhamnosus
has reduced statistically significantly the caries risk reducing S. mutans counts [79, 96],
either clinically reversed caries lesions [80], and has also prevented the development of new
lesions [81, 97].
A randomized controlled trial, published on the literature [98] examined the effect of
probiotic milk intake on concentrations of S. mutans or progression of caries. It concluded
that the milk powder containing L. paracasei SD1 was able to decrease S. mutans numbers
and delayed new caries development, suggesting that probiotics might be a way for caries
prevention.
Finally, a recent systematic review and meta-analysis were conducted aiming to answer
if dairy products containing probiotics have favorable outcomes on the oral health and
salivary parameters presented that probiotics could decrease S. mutans counts [89]. These
result concords with other systematic reviews [50, 51, 75], which also showed a reduction
in the number of this cariogenic bacteria after the use of probiotics. It suggests that dairy
products with probiotics might be a supporting form for prevention and treatment of dental caries.
12.4.4
Probiotic Powder and Dental Caries
Beyond the addition of probiotics to the above food and drinks, probiotics can also be
found in powder presentation. The product should be diluted in water and then administered orally. The consumption of a dried powdered combination of L. rhamnosus and
Bifidobacterium species and the ingestion of freeze-dried powdered preparation of
Bacillus coagulans have demonstrated positive results on the reduction of S. mutans
counts [99].
12.4.5
Probiotic Tablets and Lozenges and Dental Caries
Vehicles such as lozenges and tablets can also deliver probiotics. The lozenge is an easy and
acceptable vehicle for probiotic administration, it can be used safely in children or adults
and, mainly, as it is dissolved inside the oral cavity, there is a probiotic’s substantivity of
probiotics in the mouth [100].
Regarding the use of tablets, Çaglar et al. [101] examined if a short-term consumption
of probiotic tablets containing L. reuteri could influence the numbers of S. mutans and
Lactobacillus. The results suggest that the intake of probiotic tablets might reduce the levels of S. mutans. On the other hand, Keller et al. [102] investigated if tablets containing
Probiotic and Oral Health 181
L. reuteri could avoid the regrowth of S. mutans after disinfection with chlorhexidine, concluding that the ingestion of these tablets did not alter or delay the bacteria regrowth.
Concerning the use of lozenges, Burton et al. [103] compared the influence on active
caries indices after the use of lozenges containing S. salivarius M18. The participants
were assessed for changes to their numbers of S. salivarius, S. mutans, Lactobacillus, and
B-hemolytic streptococci. This study demonstrated that the administration of probiotic lozenges did not show a diminution in S. mutans counts.
12.4.6
Probiotic Mouthwashes and Dental Caries
As the proposed mechanisms of action of the probiotics appear to occur locally in the oral
cavity through a biofilm alteration, mouthwashes could be interesting vehicles for the probiotic administration their ability to remain in the oral cavity for hours [104].
Moreover, a single-blind randomized control study [105] test the effectiveness of the use
of probiotic mouthwash compared to chlorhexidine and fluoride mouthwashes on plaque
S. mutans level. The study concluded that all the mouthwashes were able to reduce plaque
S. mutans counts. Thus, the authors suggested that probiotic mouthwash could be effective
as an auxiliary method for oral hygiene regimen.
Accordingly, the mouthwash supplemented with L. rhamnosus B-445 demonstrated antibacterial effectiveness against S. mutans through an in vitro study [106]. The authors also
suggested that the probiotic mouthwash has a potential preventive and therapeutic value.
12.5 Periodontal Disease
12.5.1
Definition and Etiopathology
Periodontal diseases involve a variety of chronic inflammatory circumstances of the gingiva, ligament, and bone supporting the teeth. In summary, gingivitis is the dysbiosis
initiation—gingiva inflammation—and progress to the periodontitis—characterized by the
gingiva, ligament, and bone loss. Periodontitis is the more severe form of the disease, being
progressive, destructive, and creating the deep periodontal “pockets” [107].
Periodontal diseases are started and persistent by the oral microorganisms [32]. The
development of periodontitis is a microbial alteration of the subgingival biofilm, as a consequence of the interaction of the local microorganisms and the inflammatory response
[108–110].
Although the microbiome is important to the beginning and sustaining of gingivitis and
periodontitis, genetic and environmental host factors influence the dysbiosis proportion
[111]. There are several risk factors for the development of periodontal disease including
cigarette smoking, diabetes mellitus, socioeconomic and demographic variables, psychosocial factors such as stress, genetic predispositions, hormonal characteristics such as pregnancy and low immunity [112].
Regarding the periodontal microbial biofilm, it can comprise hundreds species in an
individual [113]. Subgingival communities in healthy individuals are mainly formed by
Gram-positive strains (Rothia spp. and Actinomyces spp). In contrast, the gingivitis microbial sets are formed by Gram-negative species (Prevotella, Selenomonas, and Fusobacterium)
182 Natural Oral Care in Dental Therapy
[114, 115] and periodontitis sites are characterized by a diverse community including the
species Aggregatibacter actinomycetemcomitans, Porphyromonas gingivalis, Treponema denticola, Tannerella forsythia, Filifactor alocis, and Fretibacterium spp., etc. [24].
Among these microorganisms, A. actinomycetemcomitans and P. gingivalis have been
considered as mainly responsible in the onset of periodontal disease [116–118]. On the
other hand, A. actinomycetemcomitans and P. gingivalis can also be identified in healthy
subjects [119, 120]. The dysbiosis progression is determined by the capacity of resistance of
the host immune response [107].
Prevention of gingivitis and chronic periodontitis comprises avoiding biofilm formation
through correct individual oral hygiene and eliminating the biofilm through professional
removal in regular intervals [111]. The overall recommendation is brushing the teeth twice
daily, brushing the tongue, using dental floss and fluoride toothpaste.
12.5.2
Probiotics and Periodontal Diseases
The use of probiotics in cases of periodontal diseases have been evaluated as they could
act in the suppression of periodontitis microorganisms by the production of antimicrobial
substances or through mechanisms of competition or exclusion, and also contribute to the
modulation of immune responses [121, 122]. Thus, introducing beneficial microorganisms
via probiotics products might be beneficial for the prevention of gingivitis and periodontitis
[123].
The probiotic effects against periodontal bacteria have been already studied. The influence of Lactobacillus spp. in the treatment of periodontitis has been reported as being
beneficial for the improvement of clinical periodontal parameters and reduction of
periodontitis-associated species [24].
Regarding the use of a single probiotic microorganism, L. reuteri was able to improve
periodontal clinical parameters including plaque index, bleeding on probing, and pocket
depth [124, 125]. L. reuteri has also demonstrated the capacity of significantly reducing
pocket depth and gain in moderate when used as adjunct to periodontal treatment [126]. L.
salivarius has also improved periodontal clinical parameters in individuals that consumed
the probiotic [127]; and has significantly reduced the number of periodontopathic bacteria
(A. actinomycetemcomitans, P. gingivalis, T. forsythia, T. denticola, and P. intermedia) in their
subgingival plaque [128]. Moreover, the ingestion of L. casei Shirota significantly reduced
gingival inflammation and significantly decreased plaque index in the test group [14].
Concerning the use of the association of different species of probiotic microorganisms,
the combination of L. rhamnosus and L. curvatus has reduced periodontal disease parameters after a short-term consumption [129]. However, on the other hand, the general plaque
index was less affected, although there was a tendency of decreased plaque levels in the
probiotic group [129].
Regardless of the differences between probiotic strains, a systematic review and
meta-analysis [89] showed a significantly greater plaque index after the consumption of
dairy products containing probiotics. This result may be explained because the ingestion of
probiotics-contained dairy products increases the amount of carbohydrates available [15]
in the mouth and, consequently, could increase the plaque index.
A further systematic review and meta-analysis [51] revealed that the use of probiotics did not significantly disturb the levels of periodontitis microorganisms
Probiotic and Oral Health 183
(A. actinomycetemcomitans, P. gingivalis, and P. intermedia), but it improved bleeding on
probing, gingival index, and helped in reduction of pocket probing depth. Nevertheless,
heterogeneity was elevated and publication bias suspected for all outcomes statically [51].
Two other systematic reviews focused on the effect of probiotics in periodontal disease, have
also demonstrated large heterogeneity between the randomized clinical trials included, due
to the variability of the probiotic’s strain used, the probiotic’s concentration, the delivery
vehicle, the clinical characteristics of the tested population, among others [122, 130].
Considering the above-mentioned limitations, the evidence report reductions in total
anaerobic bacteria, increases in total aerobic bacteria, reductions in black-pigmented bacteria, reductions in A. actinomycetemcomitans numbers, reductions in P. gingivalis numbers,
and reductions in T. forsythia [130].
12.6 Oral Candidiasis
12.6.1
Definition and Etiopathology
Oral candidiasis is an oral mucosa inflammation caused by the increase in the quantity of
the fungus Candida spp. [34]. Clinically, the oral candidiasis can be presented as the following forms: acute pseudomembranous candidiasis, chronic erythematous candidiasis, acute
erythematous candidiasis, and chronic hyperplastic candidiasis [31].
The infection is initiated by commensal and opportunistic species of the yeast Candida,
usually Candida albicans, which is a normal inhabitant of the oral cavity [22]. Other species
have also been associated with the infection including C. glabrata, C. tropicalis, C. parapsilosis, C. kefyr, C. dubliniensis, C. lusitaniae, C. krusei, and C. guilliermondii [24].
The biofilm formation of Candida spp. is a process of several stages being initiated
by adherence to the surface; followed by colonization, proliferation, and invasion; and
finally the detachment of biofilm cells to promote colonization and infection of other
sites [131].
Similarly to the other dysbiosis, the presence of the microorganisms exclusively is not
capable to develop the disorder. The onset of oral candidiasis occurs when there is a drop
of host immunity. This reduction in the immune response can be determined by systemic conditions including the use of medication, for example, immunosuppressive and
broad-spectrum antibiotics, age (children or elderly), chemotherapy, radiotherapy, organ
transplantation, systemic diseases, such as diabetes and malignancies, and HIV infection
[24, 88]. Moreover, there are some local factors that can also contribute to the Candida
growth including the use of removable prosthesis, poor oral hygiene, certain foods, tobacco,
and hyposalivation [132].
The most common form of candidiasis is the acute pseudomembranous candidiasis.
Clinically, its symptoms include white, curd-like patches in the mouth or throat and the
disorder is frequently characterized by local discomfort, including altered taste sensation
and burning pain [88]. When the infection becomes more serious, it may cause morbidity
and also leads to death [133].
The prevention of candidiasis is associated with the use of systemic and local antifungal
agents. However, antifungal drugs can manifest some adverse effects, such as vomiting,
diarrhea, nausea, and hepatic and renal toxicity [134]. Besides that, the resistance of the
184 Natural Oral Care in Dental Therapy
yeast to the antifungal prophylaxis caused an increase in strain number, and it remains
problematic [135, 136]. Oral candidiasis also returns or becomes recurrent in immunosuppressed patients, elderly individuals, or those wearing dentures. Thus, searching for alternative agents effective against Candida, with no side effects and no possibility of resistance
are needed [137, 138].
12.6.2
Probiotics and Oral Candidiasis
Probiotics have been used as an auxiliary to prevent and treat oral candidiasis in pediatric
and adult patients, through in vitro and in vivo studies [139]. Starting from in vitro studies,
the activity of probiotic microorganisms against Candida is important to select after an
effective strain for clinical studies. However, the results remain controversial. Probiotics
have been reported as effective agents in the reduction of C. albicans growth and against its
virulence potential [82, 140–142], while it has also been related with no inhibition in the
yeast growth [143].
Following the outcomes of clinical studies, trials have reported positive results of probiotic consumption in the reduction of oral candidiasis risk. Several investigations have shown
that the use of probiotics decreased the salivary yeast levels in test subjects [144–148], and
also expressively increased the anti-Candida IgA amounts [146, 147]. Additionally, the use
of a mix of probiotics (B. longum, L. bulgaricus, and S. thermophiles) enabled oral pain and
decline in Candida spp. counts in patients diagnosed with oral candidiasis to recover [149].
Furthermore, the consumption of capsules containing another probiotic mixture (L. rhamnosus, L. acidophillus, and B. bifidum) reduced the detection rate of oral Candida spp. in
asymptomatic patients using oral appliances [150].
The clinical effect of dairy products containing probiotics on oral candidiasis has also
been tested. Probiotic cheese significantly reduced the risk of candidiasis compared to the
control group [144, 145]. Similarly, another cheese containing different probiotic strains
tested and also presented a positive result against Candida infection [151]. On the other
hand, the consumption of cheese containing another combination of different probiotic
microorganisms could not reduce the yeast number compared to a cheese without probiotics [133].
Regarding the consumption of milk-containing probiotics, commercial fermented milk
containing L. casei and Bifidobacterium breve decreased the occurrence of oral candidiasis
in healthy individuals. Furthermore, the immunological analysis demonstrated an increment of anti-Candida IgA levels in this population, suggesting that this beverage could
control oral candidiasis [146, 147]. It is worth noting that both were clinical studies without
a control group.
Finally, at the top of the evidence, a systematic review and meta-analysis aims to assess
the efficacy of probiotics in the prevention of oral candidiasis in elderly individuals. It was
found that probiotics could be an efficient method for the reduction of oral yeast counts
in this population [88]. In contrast, another systematic review and meta-analysis focused
on outcomes of probiotics-contained dairy products on oral health, showing no significant results in yeast identification [89]. The difference between the results of these two
meta-analyses may be associated with the variation of vehicles tested. The first one [88]
included studies testing cheese, capsules, and lozenges as probiotic vehicles, and the second
study [89] included only dairy products containing probiotics.
Probiotic and Oral Health 185
12.7 Halitosis
12.7.1
Definition and Etiopathology
Bad breath or halitosis, also known as oral malodor, is an unpleasant odor exhaled from the
mouth, nasal cavity, or facial and pharyngeal sinuses. Halitosis is clinically classified into
genuine halitosis, halitophobia, and pseudo-halitosis [152]. It is estimated as the third most
common complaint of patients about oral problems, following dental caries and periodontal disease [153]. Its etiology can include reduction of salivary flux, consumption of certain
foods, presence of metabolic disorders, and respiratory tract infections [154].
Accumulation of food residues at different parts of the oral cavity and its interaction
with oral bacteria is considered the major cause of halitosis [155]. Multiple bacteria may
be related to halitosis development; among them, Atopobium parvulum, Eubacterium sulci,
and Solobacterium moorei are the dominant species located in the tongue dorsum of people
with oral halitosis [156]. Additionally, Gram-negative anaerobic bacteria (F. nucleatum, P.
gingivalis, P. intermedia, and T. denticola) are also associated with halitosis since they have
proteolytic abilities [154].
While halitosis prevention concerns the patients, the treatment of physiological halitosis,
oral pathological halitosis, and pseudo-halitosis is the responsibility of the dentists [157].
The successful management of halitosis appears to rely on the removal or reduction of
the total number of bacteria and food residuals. Mechanical interventions such as brushing teeth, using dental floss, and cleaning the tongue are intended to decrease the quantity
of these bacteria and debris [158]. In some cases, professional tooth cleaning and periodontal therapies for the removal of colonization sites of these bacteria are also necessary
[159]. However, mechanical cleaning appears to have limited benefits. The halitosis bacteria
return to the same regions shortly after the termination of therapy [160].
Chemical products such as mouth-rinses, mainly with chlorhexidine, are widely used in
the treatment of halitosis because they can get into the more inaccessible surfaces of the oral
cavity, are refreshing, and possess a pleasant odor [161]. However, chlorhexidine cannot be
used for long periods because it causes tooth and tongue discoloration and some reduction
in taste sensation [162].
12.7.2
Probiotics and Halitosis
Specific replacement of the pathogenic microbiota with favorable bacteria, such as probiotics, should be an interesting way to reduce the halitosis and prevent the growth of malodor
microorganisms [163]. As the dorsum of the tongue and periodontal tissues are the origins
of most malodor problems, probiotic species capable of colonizing these surfaces would be
a helpful method to control the halitosis [164–167].
The probiotic treatment of halitosis has already achieved promising outcomes. There are
several studies confirming the reduction of halitosis in individuals who have used lozenges,
tablets, or gums containing probiotics [164–167]. On the other hand, the supporting data
showing the efficacy of consumption of probiotics contained in dairy products in malodor
treatment are still deficient and remain poorly explored [14].
Vestman et al. [168] isolated the Lactobacillus species detected in the saliva and oral
cavity of breastfed and formula-fed infants and evaluated the in vitro probiotic proprieties.
186 Natural Oral Care in Dental Therapy
L. gasseri was the most prevalent Lactobacillus species, and this species inhibited growth
of microorganisms mainly associated with the principal oral dysbiosis: S. mutans (caries),
F. nucleatum (periodontal disease) that produces volatile sulfur compounds, C. albicans
(candidiasis), and other microorganisms [168].
An in vitro and placebo-controlled trial showed that the consumption of yogurt including L. rhamnosus L8020 reduced the S. mutans counts and four periodontal pathogens:
P. gingivalis, P. intermedia, T. forsythia, and Fusobacterium spp. It suggests that yogurt with
probiotics may diminish the risk of dental caries and periodontal disease and also periodontal pathogens related to malodor [169].
A prospective RCT showed that the administration of chewing gum containing probiotics had positive results on the reduction of oral malodor through analysis of organoleptic
scores [102]. Another clinical trial examined the influence of a probiotic tablet containing
L. salivarius and xylitol on oral malodor [170]. The study found that organoleptic scores and
concentration of volatile sulfur compounds declined in the probiotic group. Additionally,
the levels of ubiquitous bacteria and Fusobacterium nucleatum were significantly lower.
Although studies support the use of probiotics to manage halitosis, the available evidence is
insufficient for more recommendations, especially regarding the administration approaches.
12.8 Conclusion
There is no doubt about the benefits of the probiotic’s use for general health, and its use for this
purpose is largely recommended. Due to these positive effects, probiotics have been reported
as promising agents also for oral health, acting against some of the major biofilm-dependent
oral dysbiosis. However, there are still controversies over their mechanisms of action and
effects for the prevention and treatment of oral disorders, so their indication on oral health
improvement is still inconclusive. Therefore, new studies testing different probiotics products
are suggested, to recognize and describe probiotic strains that may, definitely, help in the control of dental caries, gingivitis, periodontitis, oral candidiasis, and halitosis.
Acknowledgments
This chapter was partially supported by National Council for Scientific and Technological
Development from Brazilian Government (CNPQ) process number 401058/2016-6 and
Coordination for the Improvement of Higher Education Personnel (CAPES) process number CAPES-DS 001. The authors would like to thank Cássia de Mattos de Lima for her
cooperation in the illustration of this chapter.
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13
Charcoal in Dentistry
Abhilasha Thakur*, Aditya Ganeshpurkar and Anupam Jaiswal
Shri Ram Institute of Technology-Pharmacy, Jabalpur, Madhya Pradesh, India
Abstract
Charcoal also called as “Black magic” dates its production and uses since the long ancient period.
It is a black carbon and ash residue hydrocarbon, which is very lightweight and produced by
removing water and other volatile constituents from substances of animal and vegetation origin.
It is usually produced by a method called slow pyrolysis in which wood or other substances are
heated in the absence of oxygen. The property of the product is determined by material being
charred and also the temperature at which it is charred. The different types of charcoal include
common charcoal, activated charcoal, sugar charcoal, lump charcoal, pillow-shaped briquettes,
sawdust briquette charcoal, Japanese charcoal, and extruded charcoal. Charcoal has been eagerly
adopted by the health and beauty industry. Other uses embrace it as a cooking fuel, syngas production, automotive fuel, metallurgical fuel, industrial fuel, pyrotechnics, carbon source for chemical
reactions, art, horticulture, purification, and filtration purpose, etc. Recently, an array of charcoal dentifrices has appeared in the market and is being marketed through instafamous celebrity
endorsements. These preparations remove stains, acidic plaque, and gives fresh breath, aiding in
good dental health. The microbiological studies with charcoal-infused tooth bristles also claim
lesser oral bacterial contamination. Charcoal is without doubt a health ingredient, which is in
current fashion and is a rebirth of ancient medicine techniques. However, due to lack of sufficient
clinical and laboratory data, the safety and efficacy of charcoal and charcoal-based dentifrices
cannot be claimed and hence requires well-designed studies to be conducted on a larger scale for
establishing the conclusive evidence.
Keywords: Charcoal, dentifrice, antibacterial, stain, whitens
13.1 Introduction
Oral and dental health is a necessary part of overall health and well being of an individual.
It includes disease-free teeth and supporting tissues. A healthy oral cavity can help maintain
a healthy body while its poor maintenance leads to dental cavities, gum diseases and may
be associated with heart attack, stroke, poorly controlled diabetes and preterm labor. Oral
health touches every aspect of our lives and can be called “a window into the health of one’s
body”. It can affect issues like a person’s self-esteem, speech, nutrition, comfort and overall
*Corresponding author: abhilashathakur27@gmail.com
Durgesh Nandini Chauhan, Prabhu Raj Singh, Kamal Shah, and Nagendra Singh Chauhan (eds.)
Natural Oral Care in Dental Therapy, (197–210) © 2020 Scrivener Publishing LLC
197
198 Natural Oral Care in Dental Therapy
quality of life [1–2]. The World Health Organization declared the theme “Oral Health for a
Healthy Life” on World Health Day in 1994 [3].
Various materials and methods are suggested and are in use for maintaining oral hygiene.
Table 13.1 enlist major over-the-counter (OTC) dental products with their main uses [4],
and Figures 13.1 and 13.2 depict the different types of materials and instruments used for
oral hygiene [1].
Table 13.1 OTC dental care products with their main use.
OTC dental care products
Use
1. Mouth fresheners
Treatment method for halitosis.
2. Abrasive stain removers
Along with removing dental stains, claims to
remove plaque, tartar and tobacco stains.
3. Pregnancy toothpaste
Specially formulated for pregnant and lactating
women.
4. Charcoal toothpaste and charcoal
brushes
Charcoal has the ability to kill microbes and
absorb gases causing malodor.
5. Whitening agents/pastes
Stain removal and whitening of teeth.
Datun
Ayurvedic
toothpowder-red
Ayurvedic
toothpaste
Non-medicated
toothpaste
Materials for oral
hygiene
Non-abrasive
white toothpowder
Desensitizing
toothpaste
Figure 13.1 Different types of materials used for oral hygiene.
Oral hygiene instruments
Finger
Toothbrush
Proxa brush
Figure 13.2 Different oral hygiene instruments.
Charcoal in Dentistry 199
Charcoals containing oral and dental care preparations are a recent innovation in the
oral healthcare product market. The marketing campaign for these preparations is fashionable, trendy and so is enjoying considerable success. So it can be said without doubt
that charcoal is a current fashion in health ingredient and is the rebirth of ancient medicine techniques.
Charcoal largely consists of black carbon and ash residue hydrocarbon produced by
removing water and other volatile constituents from substances of animal and vegetation
origin. It is generally produced by a method called slow pyrolysis in which the wood or
other substances are heated in the absence of oxygen [5].
13.2 Charcoal Production Methods
The production of charcoal is being done since very ancient period. These methods can be
broadly divided into:
13.2.1
The Traditional Method
The method utilizes a clamp and is basically a pile of wooden logs placed in a circle,
which leans against a chimney consisting of four wooden stakes being held up by ropes.
These logs are then totally covered with soil and straw so that no air enters. Utilizing
some burning fuel, the chimney is lit, and the logs are allowed to burn very slowly to
transform into charcoal in a period of about 5 days. As the burning is complete, to prevent air from entering, the chimney is plugged [6]. However due to emissions of unburnt
methane, this method has a strong inherent disadvantage of being hazardous to human
health and environment [7]. Also, partial combustion of wood imparts low efficiency to
this method.
13.2.2
The Modern Methods
The methods provide a high yield of about 35–40% as it utilized retorting technology, i.e.,
process heat is recovered, rather than kilning [7].
The properties of the obtained charcoal depend on the material being charred and also
the temperature at which it is charred. It contains different amounts of hydrogen and oxygen, ash, and other impurities. These, together with the structure, define the properties of
the charcoal produced. The source material, which is free from non-volatile compounds,
produces high purity product.
200 Natural Oral Care in Dental Therapy
Table 13.2 Various types of charcoal.
Common charcoal
Made from wood, coal, coconut shell, peat, or petroleum.
Sugar charcoal
Obtained from the carbonization of sugar. Later to remove any
mineral matter, purified by boiling with acids. Then after to
remove the last traces of hydrogen, it is burned for a long time
in a current of chlorine [8].
Activated charcoal
Produced from coal, coconut shells, bone char, sawdust, peat,
petroleum coke, or olive pits.
By processing it at very high temperatures, the charcoal is activated
leading to change in its internal structure, making it more porous,
reducing the size of its pores, and increasing its surface area [9, 10].
Lump charcoal
It is a conventional charcoal made from hardwood material and
as compared with briquettes produces less ash.
Japanese charcoal
During the charcoal making pyroligneous acid is removed from it
and hence when burned, it produces nearly no smoke or smell.
Pillow shaped briquettes
These are generally made from sawdust and other wood
by-products, by compressing charcoal with a binder and other
additives. Starch is used as binder and may include brown
coal and mineral carbon as a heat source while borax, sodium
nitrate, and raw sawdust are used as ignition aid. Other
additives include limestone as ash-whitening agent.
Sawdust briquette charcoal
Produced by compressing sawdust without binders or other
additives. It is used primarily for barbecue as it produces high
heat but no smoke and odor with little ash. It has long burning
hours which may exceed 4 h.
Extruded charcoal
Produced by extruding raw ground wood or carbonized wood
into logs without using a binder. The charcoal is held together
by the heat and pressure of the extruding process.
13.3 Uses of Charcoal
Charcoal is being used since ancient times for different purposes including medicinal and
nonmedicinal areas.
13.3.1
Medicinal Uses
Teeth whitening, oral health charcoal toothpaste and dentifrices,
Charcoal tablets, capsules or powder for digestive effects [11],
To measure the mucociliary transport [12],
Treatment of poisoning or drug overdose,
To relieve kidney dialysis treatment related itching [13],
To reduce high cholesterol,
Charcoal in Dentistry 201
Mold cleansing [14]
Treatment of skin infection [15]
13.3.2
Non-Medicinal Uses
Metallurgical fuel ex-production of Iron [16]
Industrial fuel ex-blast furnaces
Cooking fuel ex-charcoal briquettes
Syngas production ex-automotive propulsion
Pyrotechnics ex-black powder for fireworks
Cosmetic ex-bamboo charcoal for its absorbing properties
Carbon source ex-chemical reactions
Purification ex-sucrose from cane sugar
Filtration ex-charcoal filters in gas masks
Art ex-drawing and painting
Horticulture ex-biochar
Animal husbandry ex-mixed with feed
13.4 Charcoal Containing Oral and Dental Care Products
A charcoal containing oral and dental care product may include charcoal as an ingredient
as activated form of carbon, charcoal, raw charcoal, black charcoal, organic charcoal, premium charcoal, premium-grade charcoal, white charcoal, bamboo charcoal, all-natural
bamboo charcoal, coconut charcoal, coconut shell charcoal, organic coconut charcoal,
medical-grade charcoal, negative ionic charges of charcoal, pure hardwood charcoal, virgin carbon hardwood-derived, or active pine tree charcoal. Other forms include charcoal power, bamboo charcoal, natural bamboo charcoal, bamboo charcoal all-purpose,
white charcoal, coconut charcoal, American eastern hardwood charcoal, and ecologic
charcoal [17].
These products can be searched in the market as toothpowder (Healthvit coconut shellactivated charcoal instant teeth whitening powder), toothpaste (Healthvit-activated charcoal toothpaste, Colgate Total charcoal anticavity toothpaste, Beverly Hills white black
formula perfect toothpaste), tooth tabs (Lush Boom Tooth Tabs), capsules (FineVine
organic coconut activated charcoal capsules), dental creams [18], tooth polish (Diamond
Whites Black Edition Tooth Polish) etc. John et al. 2017 reviewed the safety and efficacy of
charcoal and charcoal-based dentifrices [17].
In certain countries nowadays, charcoal has been imparted to the bristles of toothbrushes, making appearance of the bristles black in color. Charcoal has inherent property
of being absorbent for toxins, poisons, and noxious gases. Thus, the charcoal-infused
tooth bristles can be considered a new product to prevent bacterial contamination [19].
Manufacturers of these charcoal toothbrushes claim that by using these charcoal blended
nylon bristles, halitosis, and plaque can be reduced. Along with these advantages it also
kills bacteria that may develop in the bristles during storage [19, 20]. Teraoka et al. 2004
studied the far infrared spectral characteristics of bamboo charcoal powder. Based on the
study and its effect on cancer cells for use in the dental field they proved bamboo charcoal
202 Natural Oral Care in Dental Therapy
Table 13.3 Patents for inventions/formulations containing charcoal.
Formulation/invention
Claim
Ref.
Bamboo charcoal toothpaste
Bamboo charcoal fiber layer provides fresh taste
and also reduces resource wastage.
[26]
Active carbon toothpaste
Prevents and treats periodentitis, gingivitis,
strengthened oral health, tooth decolorizing,
and whitening effect.
[27]
A kind of Blumea balsamifera
bamboo charcoal toothpaste
Relieve bacteriostatic itching and eliminate oral
peculiar smell.
[28]
Bamboo charcoal toothpaste
capable of refreshing mouth
smell and whitening teeth
Refreshing mouth smell, whitens teeth, and highly
stable.
[29]
Toothpaste using charcoal and
negative ions
Absorbs heavy metals and bacteria. Surfactants
present in dentifrice generate anions.
[30]
Toothpaste composition
Toothpaste composition at a low production cost.
Bamboo charcoal and bamboo vinegar has
good deodorizing and bactericidal power and
tranquilizing effect.
[31]
Chinese body containing carbon
black fashion toothpaste
Dental cleaning and healthy gingival homeostatic
efficacy.
[32]
A toothpaste having a charcoal
Effective in periodentitis, whitening, and
deodorization effect.
[33]
Bamboo charcoal-lavender
toothpaste
Bamboo charcoal adsorbs dirt from oral cavity and
reduces bacteria survival. Lavender fragrance
improves smell in the oral cavity, resists bacteria,
protects nerves, and relieves oral cavity pains.
[34]
Bamboo charcoal toothbrush
Gingival massage rings arranged on the toothbrush
head remove food debris, cleans teeth, and
remove dental plaque. The flexible bulges
arranged at the back side of the toothbrush head
remove leftover blots on inner walls and tongue.
[35]
Therapeutic chew device for
cleaning teeth and breath of dogs
Absorbs odors and bacteria to clean and freshen
the dog’s breath.
[36]
Tooth paste composition
Combination of a detergent base and a mixture
of micronized colloidal silica gel and activated
charcoal.
[37]
Double capsule composition
for containing charcoal and
manufacturing method for the
same
Uses charcoal powder to make a double capsule
which maintains a color in a bright tone even after
mixing in toothpaste. Original color revealed only
when during use, capsule is destroyed.
[38]
(Continued)
Charcoal in Dentistry 203
Table 13.3 Patents for inventions/formulations containing charcoal. (Continued)
Formulation/invention
Claim
Ref.
Outer remove intrinsic stains
toothpaste
Removes extrinsic stains, plaque, food debris, and
dirt from the teeth surface.
[39]
Toothpaste containing bamboo
activated carbon
Removes foreign smell and stains deposited on the
teeth.
[40]
Toothpaste adopting spherical
activated carbon and preparation
method of toothpaste
Good cleaning and stain adsorbing effect.
[41]
Toothbrush having brush made of
material comprising charcoal
powder
Antibacterial, deodorizing, and cleansing effect.
[42]
Hardwood charcoal toothpaste
Removes mouth odor, prevents tooth decay, and
periodontal disease.
[43]
Charcoal powder-containing
dentifrice composition for
removing nicotine
Removes and prevents nicotine accumulation
from the teeth.
[44]
Toothpastes containing powdered
charcoal- having enhanced
whitening effect on teeth
Compared to conventional toothpastes increased
whitening action, especially in heavy smokers.
[45]
Multi-functional bamboo charcoal
toothbrush
Toothpaste–toothbrush integration.
[46]
Dentifrice paste containing
charcoal as abrasive has
additional purifying action
Satisfactory abrasive, absorbing, and purifying
effect particularly for stains and bacteria.
[47]
Bamboo charcoal composition
for removing bad breath as
well as preparation method of
composition
Due to strong adsorption power, removes the bad
breath.
[48]
Aqueous charcoal-containing
slurry for removal of plaque,
calculus or stains from teeth
Capable of removing plaque, calculus and stains
from teeth.
[49]
Aaaaa
Alleviate toxicity and removes odor.
[50]
Dentifrice included charcoal
Sterilizes microorganism generated in the mouth,
deodorization effect.
[51]
Manufacturing process of charcoal
toothpaste
Charcoal toothpaste prepared by the method
eliminates acid associated toxicity, produces
good energy to human body by far-infrared raylike effect and anti-inflammatory effect without
side effects.
[52]
204 Natural Oral Care in Dental Therapy
powder to be a promising dental filler material for prevention of cancer [21]. Thamke
et al. 2018 evaluated the bacterial contamination and antimicrobial efficacy of charcoal
bristles compared to noncharcoal bristles in used toothbrushes. The study showed a statistically significant difference in bacterial counts between bristle types and lower CFUs
in the charcoal bristles compared with noncharcoal bristles, after 1 week of use. The zone
of inhibition that was found around charcoal tooth bristles supported the antimicrobial properties of the charcoal toothbrush [22]. Through different studies, it has been
proven that activated carbon has capacity to remove bacteria like Pseudomonas aeruginosa and Escherichia coli from fresh and potable water systems [23, 24]. Microorganisms
get attached to activated carbon particles via strong Lifshitz van der Waals forces [25].
Although there is electrostatic repulsion between negatively charged microorganisms and
carbon surfaces, there remains a possibility of enhancing the microorganism-removing
efficacy of activated carbon efficacy by positive charge modification of the carbon particles surfaces.
13.5 Benefits of Using Charcoal Containing Oral
and Dental Care Products
13.5.1
Removes Stains and Whitens Teeth
The activated charcoal in a toothpaste works by mechanism of combination of mild abrasion and absorption of extrinsic tooth surface stains. Charcoal present in these products
does not stick to the teeth surface and hence could be easily washed away. Its absorbent
properties allow it to only bind with the surface stains like those from coffee and tea.
However, it may not be beneficial on yellowed teeth due to antibiotics or other internal
problems [53, 54]. So these products are an effective means to remove extrinsic stains, i.e.,
discoloration of outside surface of the tooth from substances like coffee, wine, berries,
and other staining foods [55]. These products may be found to be most effective when
used to delay the recurrence of surface staining on intact teeth following professional
cleaning and polishing [56]. Also brushing teeth with the activated charcoal regularly
has been reported to enhance the teeth appearance making them lighter by up to three
shades [57].
13.5.2
Removes Acidic Plaque
Charcoal has binding capacity to the acidic elements present in mouth and thus increases
their rate of excretion from the body. Hence brushing with these types of toothpaste raises
the pH of mouth and helps in reducing the buildup of acidic plaque [58].
13.5.3
Gives Fresh Breath and Improves Halitosis
Due to its absorbent qualities, charcoal helps in controlling halitosis.
Charcoal in Dentistry 205
Removes stains and whitens teeth
Removes acidic plaque
Improves halitosis
Activated Charcoal
Remineralizes teeth
Protects from infection
Cost effective for regular basis use
Figure 13.3 Benefits of using charcoal containing oral and dental care products.
13.5.4
Remineralize Teeth
Activated charcoal has been used by many people as part of their teeth remineralizing protocol. However, there is a myth that charcoal demineralizes the teeth. However, as activated
charcoal binds mostly to organic compounds and not minerals, it does not pull out the
calcium from the teeth [59].
13.5.5
Helps Overall Dental Health
Using these products is quite messy and makes mouth look black, but as charcoal present
in these products does not stick to the teeth surface, the product can be completely washed
out by rinsing leaving teeth clean and smooth.
13.5.6
Protects From Infection
There have been some suggestions that charcoal particles left in the mouth after brushing
may have certain antimicrobial effects [56]. Charcoal has the property to pull toxins from
the surface of teeth and the mouth. It binds with the toxins and come out of the oral cavity
during rinsing of the mouth. As it has capacity to change the pH of the mouth, it does not
allow disease causing germs and bacteria to thrive and reproduce within the mouth rendering it safe and clean. So these products protect teeth from infections causing bacteria
and other microorganisms [59]. Also, there are millions of tiny pores present in activated
charcoal, which trap toxins and harmful chemicals [55].
13.5.7
Cost Effective for Regular Basis Use
Apart from the above-mentioned benefits, one important advantage of these charcoal containing dental products is that it is a cost-effective solution for a regular basis use.
206 Natural Oral Care in Dental Therapy
13.6 Precautions to be Taken While Using Charcoal Containing
Oral and Dental Care Products
Clinicians, researchers, and patients have shown alarm in using charcoal and charcoalcontaining products for dental care due to the risk of thinning of the dental structure.
Unlike materials such as salt, charcoal was not found to abrade teeth. However, these products are black in color, and brushing off the color tends to prolong brushing, or the use of
excessive brushing force, which may lead to the abrasion of teeth [56]. If activated charcoal
is used very frequently or in an incorrect manner, it can cause eroding of the enamel. Also,
a regular use of abrasive material like charcoal may scrub out surface stains making teeth
look whiter. However, this effect is for short term. Later, regular use of these product leads
to teeth eventually looking yellower due to wearing of enamel causing permanent damage.
A loss of enamel can lead to exposure of dentin, increased sensitivity, and increased susceptibility to dental decay [60–62].
Particles of charcoal included in charcoal powder and toothpaste may accumulate in
crevices and other defects in teeth. These particles of charcoal may also build up in gaps
between the teeth and dental restorations resulting in a grey or black line around restoration margins. This would create negative effects on dental attractiveness and may necessitate the replacement of the affected fillings, veneers, or crowns [56].
The powdered formulations generally require a longer brushing time to acquire
the whitening effect and its use tend to be messy. Therefore, compared with pastes, the
charcoal-containing dental powders are recommended for shorter period use, which is on
an average once a day for 3 to 5 days rather than every day [63].
Many of these products contain agents like sodium laurel sulfate (SLS), which may cause
gingival irritation in some individuals. So a good quality charcoal toothpaste products
should be free of agents like sodium lauryl sulfate and artificial sweeteners like erythritol
and fluoride [55, 63].
While using a charcoal dentifrice instead of scrubbing it hard on teeth surface, one
should brush gently in a circular motion and then after mouth should be rinsed until it spits
out totally clear of any discoloration from the toothpaste. These may also be tried smearing
it on teeth, letting it sit for 5 to 10 min and then allowing it to do its adsorptive action. This
procedure is particularly advisable with issues like childhood illnesses, medication reactions, etc., and related enamel erosion [55].
Charcoal dentifrices should not be used every day. As a rule of thumb, in order to avoid
any negative side effects, 2–3 days a week is the optimum schedule [55]. Many dental specialists suggest the use of activated charcoal toothpaste with caution and not for extended
periods. Other reasons for cautions involve recession of gum tissue due to the abrasive
quality of charcoal toothpaste causing teeth sensitivity. Hence, dentists recommend using
charcoal toothpaste manufactured by reputable brands, and proper note should be taken of
any unusual symptoms that might appear during its use like increased sensitivity or bleeding gums [59, 64].
Charcoal in Dentistry 207
13.7 Conclusion
Charcoal has been eagerly adopted by the health and beauty industry. The marketing campaigns for these toothpastes are fashionable and trendy, and so considerable success was
enjoyed. It is undoubtedly the current fashionable health ingredient and is a rebirth of
ancient medicine techniques. However, there is still a lack of sufficient scientific evidence,
which can authenticate the cosmetic, health benefits including antibacterial, antifungal, or
antiviral activity, reduced caries, tooth whitening, oral detoxification, or safety claims of
marketed charcoal-based oral and dental care products. Also, controlled clinical trials and
laboratory investigations of such products are needed to determine product efficacy and
safety. To our knowledge, till date, no charcoal-based dental preparation has been approved
by any dental organizations.
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14
Propolis Benefits in Oral Health
Mariana Leonel Martins1, Karla Lorene de França Leite1, Yuri Wanderley Cavalcanti2,
Lucianne Cople Maia1 and Andréa Fonseca-Gonçalves1*
1
Department of Pediatric Dentistry and Orthodontics, School of Dentistry, Universidade Federal do
Rio de Janeiro (UFRJ), Rio de Janeiro, Brazil
2
Department of Clinical and Social Dentistry, Universidade Federal da Paraíba, João Pessoa, PB, Brazil
Abstract
The use of phytotherapy in medicine has given prominence to some natural products such as propolis, which consists of a resin produced by bees that is gathered from the shoots and exudates of plants.
This product can be found in different countries such as Russia, China, Brazil, Cuba, Chile, and
Turkey. The specific physicochemical characteristics of propolis are determined by its chemical composition, especially its phenolic compounds, and its main botanical origin, being classified as either
red (Dalbergia ecastophyllum), green (Baccharis dracunculifolia), or brown (without specific main
botanical origin). The variety of propolis compounds, such as flavonoids, appears to confer different
biological properties to this product resulting in activities from antibacterial, antifungal, and antioxidant to anti-inflammatory, and anticancer. However, its bioactive compounds vary according to the
climatic conditions, such as temperature and season. Different types of propolis have been evaluated
in order to be applied in dentistry, mainly due to its effectiveness on the cariogenic biofilm control
and fungal infections and in the case of periodontal disease or root canal contamination. Laboratory
studies and clinical trials with propolis in different presentation forms have demonstrated a positive effect of this product against oral pathogens. In this sense, the present chapter aims to offer an
updated review of the benefits of propolis from the perspective in oral health.
Keywords: Propolis, phytotherapy, antibacterial agents, anti-infective agents, oral health
14.1 Introduction
Propolis consists of a resinous matrix arising from the extraction of botanical compounds
by bees that are added to substances secreted by their glandular metabolism in order to
reduce the size of the entrance of the hive and protect it from invaders (Figure 14.1). This
product also serves as an antiseptic inside the alveoli, where the queen bee lays the eggs
(Figure 14.2), and for wrapping up intruders slaughtered inside the hive to prevent them
from rotting and contaminating the nest (Figure 14.3). Propolis contains waxes, resins, balsams, oils, and pollen and may present variable color, taste, odor, consistency, and chemical
*Corresponding author: andrea.goncalves@odonto.ufrj.com
Durgesh Nandini Chauhan, Prabhu Raj Singh, Kamal Shah, and Nagendra Singh Chauhan (eds.)
Natural Oral Care in Dental Therapy, (211–228) © 2020 Scrivener Publishing LLC
211
212 Natural Oral Care in Dental Therapy
Figure 14.1 Worker of Apis mellifera in sunflower blossom. Fototeca Cristiano Menezes (FCM) available at
speciesLink network (http://www.splink.org.br) in 2019, Feb 22.
Figure 14.2 Larvae of Apis mellifera in the honeycomb with propolis. Fototeca Cristiano Menezes (FCM)
available at speciesLink network (http://www.splink.org.br) in 2019, Feb 22.
Figure 14.3 Entrance of Tetragonisca angustula with carcasses of ants mummified with propolis. Fototeca
Cristiano Menezes (FCM) available at speciesLink network (http://www.splink.org.br) in 2019, Feb 22.
Propolis Benefits in Oral Health 213
composition as well as biological activity depending mainly on the plant species of origin
and the season in which the product was created [1–3].
This product can be found in different countries, such as Russia [4], China [5], Brazil
[6–8], Cuba [9], Chile [10, 11], and Turkey [12]. In addition, it is known that various types
of propolis can be found in the same country as a result of biodiversity, but the quality varies from one region to another due to environmental factors. Therefore, it is recommended
that the determination of the type of propolis be established according to its main plant
source [13].
Propolis has been prominent in the international trade of apicultural products due to the
diverse biological properties attributed to its chemical components, which consequently
increase its aggregated value and the interest in performing propolis-centered research
studies [14].
Thus, an increase in propolis use has been observed principally due to the major interest in natural products. The applicability of propolis may constitute a viable alternative for
the treatment of oral diseases, since many types of propolis have proven to present biological properties [15–18]. However, it is necessary to know the composition and mechanism of action of these products in order to potentiate the expected results and avoid
adverse effects [8].
14.2 Types of Propolis
As mentioned before, there exist different types of propolis (i.e., yellow, dark yellow, light
brown, dark brown, greenish-brown, reddish-brown, green, and red), which can be classified by botanical origin and, consequently, by the main chemical components [13]. The
chemical compounds isolated from propolis can be organized into the following main
groups: aromatic esters, sugars, alcohols, aldehydes, fatty acids, amino acids, steroids, flavonoids (i.e., flavones, flavonols, flavonones, flavanones), terpenoids, proteins, vitamins, and
minerals [19–24].
In Brazil specifically, propolis can be classified into 13 different types according to its
physicochemical properties and the geographic area in which it was found and presents
a color variation from yellow to brown. However, of these, the main types of propolis are
brown, green, and red [13, 25], and these types can be also found in other countries such as
Mexico [26], Cuba [9], Taiwan [27], and Turkey [12].
The chemical analysis of propolis is difficult because it is a mixture of substances that
presents high variability. This analysis has been more thoroughly performed involving
the aqueous and ethanolic extracts (Figure 14.4), since they are the most used presentation forms in several types of therapeutic applications [5–8, 28].
14.2.1
Brown Propolis
Brown propolis does not present a specific main botanical origin. The European
brown propolis comes from the resins of the Populus spp. (P. alba, P. nigra, P. tremula) [20], while the Cuban brown propolis has its major origin source attributed to the
Clusia spp. [29].
214 Natural Oral Care in Dental Therapy
Figure 14.4 Ethanolic extracts of propolis from southeastern Brazil, southern Chile, and northeastern Brazil
(from left to right). Personal file.
In its composition are found artepillin C, kaempferide, p-coumaric acid, chlorogenic
acid, pinocembrin, p-hydroxybenzoic acid, galangin, chrisin, and pinobanksin, among others [25, 30]. These compounds are associated with the preventive effect of brown propolis in
healthy subjects, avoiding the development of cardiovascular disease, diabetes, and cancer
[30] and presenting activity against oral bacteria [31].
14.2.2
Green Propolis
Green propolis originates from Brazil and has its major plant source present in the
Baccharis spp., especially the Baccharis dracunculifolia (called “wild rosemary” in Brazil).
This vegetable is very common to find in vacant lots and other open places because it
needs a lot of light to survive. The most prevalent compounds of Brazilian green propolis
are kaempferide, p-coumaric acid, kaempferol, artepillin C, ferulic acid, caffeic acid, and
pinocembrin [7, 25]. The overvaluation of this propolis is mainly explained due to the
antibacterial, antitumor, and anti-inflammatory activities of artepillin C and p-coumaric
acid, which can be found in higher concentrations in this type of propolis as compared
with any other type [25].
14.2.3
Red Propolis
Red propolis comes mainly from plants of the gender Dalbergia, which are found in different species such as Dalbergia odorifera and Dalbergia ecastophyllum (popularly known as
“howler monkey’s tail” in Brazil). These plants can be found near beaches and riverbanks
and mangroves as a result of their preference for saline environments [2, 22] (Figures 14.5
and 14.6).
This product is composed of several classes of flavonoids, such as flavone (rutin,
luteolin), isoflavone (formononetin, daidzein), and dihydroflavonol (pinobanksin,
Propolis Benefits in Oral Health 215
Figure 14.5 Raw red propolis from Southeastern Brazil. Personal file.
Figure 14.6 Raw red propolis from Northeastern Brazil. Personal file.
pinobanksin-3-acetate), which are mainly compounds associated with the biological activities of this group of propolis [6, 8, 22]. It is known that antioxidant and antimicrobial
substances exist in higher concentrations in the hexane fraction than in the crude extract of
red propolis [32]. A phenolic acid and seven flavonoids present in crude propolis as well as
the extract and hexane fraction were quantified in a laboratory study, which revealed that
formononetin and pinocembrin were the main constituents [33] (Table 14.1).
14.3 Biological Properties of Propolis
The significant use of the propolis extract has been associated with its antimicrobial, antiinflammatory, healing, anesthetic, and antioxidant actions, supporting its diverse applicability [6, 11, 34–36]. The preparation and presentation form of this product, among other
factors, may result in biological properties with different potentials. Ethanol is considered
216 Natural Oral Care in Dental Therapy
Table 14.1 Mean concentration (μg/mL) of compounds isolated from raw red
propolis (powder), the ethanolic extract, and the hexane fraction.
Compounds isolated
from red propolis
Mean concentration (μg/mL)
Raw
Ethanolic extract
Hexane fraction
Ferulic acid
1.17
0.54
0.25
Biochanin A
0.54
0.36
0.32
Daidzein
0.19
0.01
0.03
Formononetin
7.21
2.28
2.47
Luteolin
0.65
1.06
0.6
Pinocembrin
3.32
2.19
2.33
Rutin
0.36
0.20
0.19
Quercetin
1.13
0.38
0.39
Total
14.57
7.02
6.58
Source: Das Neves et al. (2016) [33].
the most used solvent to obtain propolis extracts, because of the interaction of the chemical
characteristics with the propolis matrix [37], in addition solvents such as ethyl ether, water
and chloroform can be considered good constituents for the production of extracts [22, 37].
14.3.1
Oral Antibacterial Activity
Given that synthetic products, such as antimicrobials, when used for a long period, cause
microbial resistance, loss of gustatory sensitivity, and pigmentation of the teeth and mucosa,
the search for equivalent biocompatible alternatives that control the imbalance of the oral
microbiota homeostasis becomes relevant [38].
In this way, propolis appears as an alternative treatment, since it has demonstrated antimicrobial activity and, for this reason, the product has been an object of frequent study in
the design of new products with potential clinical application [6–8, 39–42]. In addition,
propolis inhibits glycosyltransferases and oral bacteria involved in the caries process such as
Streptococcus mutans [7, 8] and Streptococcus sanguinis [43]. These effects may be observed
at varying levels depending on seasonality and the site of product collection, which interfere
with the concentration of biologically active compounds present in the propolis [6, 11].
The antibacterial activity of propolis can be attributed to phenolic compounds, which
inhibit the adhesion of bacteria to the surface of the teeth, reducing the production of the
enzyme glycosyltransferase, an enzyme that is responsible for the production of extracellular polysaccharides [44], amylase, and acids derived from food fermentation besides controlling the demineralization of the enamel [45, 46].
A Brazilian brown propolis (20% and 40%) was previously tested as an intracanal medication in association or not with calcium hydroxide paste and successfully reduced the
Propolis Benefits in Oral Health 217
number of Enterococcus faecalis viable after 14 days of assay [31]. Another study verified that
brown propolis extracts exhibited the lowest antimicrobial activity against Staphylococcus
aureus (ATCC no. 25923) compared with green and red propolis extracts and showed a similar effect as that of the green extract against Enterococcus spp. (ATCC no. 2912), Klebsiella
spp. (ATCC no. 1706/700603), and Escherichia coli (ATCC no. 25922) [47].
A Taiwanese green propolis extract exhibited significant antibacterial activity, principally against Gram-positive bacterial strains [27], similar to that observed with an ethanolic extract of Brazilian green propolis (3%) used to control oral hygiene after minor oral
surgery [48]. Separately, another extract of Brazilian green propolis reduced the number of
bacteria present in the S. mutans biofilm and inhibited the demineralization process [7] in
a manner similar to the outcome observed with a red propolis extract [8].
The antimicrobial activity of red propolis was verified against several microorganisms
related to the oral cavity, such as S. mutans [6–8], Streptococcus sobrinus [6, 14], Actinomyces
naeslundii [6], Enterococcus spp. [31, 47], and Staphylococcus aureus [6, 47]. An ethanolic
extract of red propolis presented activity against both Gram-positive (100%) and Gramnegative (62.5%) strains [49]. Other research revealed that purified vestitol and neovestitol,
isoflavonoids isolated from a Brazilian red propolis, presented better antimicrobial activity
than did the raw, chloroform, or hexane extracts [39, 40].
In a study, a solution containing alcohol-free propolis (2%) was evaluated for its efficacy
in reducing the salivary levels of the mutans streptococci and lactobacilli and regarding
patient acceptability of the product. After 28 days of treatment (2×/day), it was found that
the propolis group presented, at different times, better results than either the chlorhexidine
group or the placebo group for both microorganisms. In addition, propolis presented a
greater residual effect after 17 days of discontinuation of its use and was the product with a
greater percentage of patient satisfaction and acceptability [50].
Elsewhere, a propolis tincture, even at low concentrations, reduced more than 99%
of microorganisms after 10 min of exposure, suggesting its use in controlling biofilmassociated infections [51], while in other study in vivo, a dentifrice with propolis led to a
reduction in the microbial of S. mutans in the oral cavities of young patients [52].
A review showed that different presentation forms of propolis (e.g., extracts, isolated
fractions, purified compounds) reduced strains of S. mutans, besides that glucosyltransferase activity and their adhesion capacity [3]. Other studies in vivo have demonstrated
reductions in S. mutans counts in saliva [53, 54] as well as decreases insoluble polysaccharide formation and plaque index [55] with the use of propolis. Therefore, propolis can be
considered as a promising cariostatic agent for routine clinical use [3].
Considering the propolis mechanism of action in relation to its antibacterial properties,
pinocembrin, galangin, and caffeic acid phenylethyl ester are some phenolic compounds
found in propolis that probably inhibit the bacterial RNA polymerase [56]. Other propolis
components with antimicrobial properties such as flavonoids, benzoic acid, and cinnamic
acid as well as caffeic acid interact specifically with the cell wall of bacteria, causing cell lysis
and bacterial death [4]. This finding suggests that propolis causes bacterial death through
functional and structural damage, but it is known that the antibacterial activity is greater
against Gram-negative bacteria and limited against Gram-positive bacteria, probably the
greatest resistance is due to the presence of the chemical composition of the wall being
more complex and having a higher lipid content (Figure 14.7A, B). The mechanism of propolis to inhibit the growth of Gram-positive strains remains unclear to date [27].
218 Natural Oral Care in Dental Therapy
(a)
(b) Antibacterial Action
Mechanism
Raw Propolis and
Extracts
Site of propolis action
B1) RNA polymerase
3’
5’
5’
DNA
RNA polymerase
3’
RNAtranscript
5’
B2) Bacterial Cell Wall
Gram-positive
bacteria
Lipopolysaccharide
Peptidoglycan
Gram-negative
bacteria
Outer
Membrane
Cell wall
Cell wall
Site of
propolis
action
Periplasmic
gel
Site of
propolis
action
Plasma
membrane
Plasma
membrane
Protein
Gram-negative
cell wall
Gram-positive
cell wall
(c) Antifungal Action
Mechanism
(d)
Anticancer Action
Mechanism
Effect on the transition
from yeast to hyphae
D1) Suppress cancer
cell proliferation via
anti-inflammatory effects
D2) Reduces the cancer
stem cell population
Hyphae
Yeasts
D3) Blocks specific
oncogene-signalling
pathways
D4) Exerts
antiangiogenic
effects
Pseudohyphae
D5) Modulating the tumour
microenvironment
Figure 14.7 Action mechanism of propolis: A) raw propolis and extracts; B) antibacterial action mechanism
by inhibition of the bacterial RNA polymerase—B1 (Adapted from Carbonaro, T.M., 2011) or via bacterial cell
wall, causing cell lysis and bacterial death—B2 (Adapted from Person Education. Inc., University of Colorado,
Denver, publishing in Benjamin Cummings); C) Antifungal action for inhibiting the initial stages of infection
processes; D) Anticancer action mechanism (Adapted from Instituto Vencer o Câncer).
Propolis Benefits in Oral Health 219
14.3.2
Oral Antifungal Activity
Systemic candidiasis is a fungal infection considered a public health problem due to the
growing proliferation of multidrug-resistant Candida species [57]. The mechanisms of
resistance of these microorganisms may be related to alterations in drug targets involving
changes in membrane sterol, membrane-localized drug efflux pump assays at the functional
and transcriptional levels, and reduced or limited drug penetration through biofilms [58].
To overcome fungal resistance, it is necessary to control the proliferation of Candida
species without the drug causing a fungicidal effect [59]—that is, the microorganism must
be in symbiosis with the human microbiota instead of being eliminated [60]. In this sense,
the antifungal action of propolis is related to reducing, controlling, or removing the fungal
agent; despite being a natural product, it is expected to interfere with the production of virulence factors and resistance to drugs at low doses [35, 61]. Probably, this antifungal action
may be related to the synergistic activity between the phenolic compounds and flavonoids
present in propolis [62]. Thus, there is an urgent need for new therapeutic approaches for
candidiasis as a complementary treatment to synthetic fungicides, including strategies that
use natural products such as propolis.
Investigations must be carried out not only to find new compounds with action against
Candida but also to elucidate the mechanisms of action of natural products like propolis,
since this microorganism is a dimorphic fungus, possessing a yeast form that is associated
with asymptomatic colonization and a filamentous form involved in pathological processes
and favors adaptation in different biological niches [58]. For this reason, the formation of
hyphae contributes to the fungus penetrating the host tissues, leading to the establishment
of infection [63]. Thus, the action of propolis is involved in the initial stages of infection
processes, in which its effect affects the transition from yeasts to hyphae, considered a critical attribute in the virulence of C. albicans (Figure 14.7C) [64].
Due to the difficulty that exists in comparing the antifungal activity among the propolis
varieties, there is evidence that supports the use of this natural product as a therapeutic for
this problem. In studies that evaluated the action of the hydroalcoholic extract of propolis green (30%; Brazil) against Candida isolates, a greater effect against C. albicans and
C. parapsilosis was observed when compared with C. tropicalis cells. In addition, propolis
prevented the biofilm growth of Candida spp. and was able to eradicate the more mature
biofilms, as well as to reduce the filamentation of C. tropicalis and C. albicans [64].
In one study, 50 ethanolic extracts of propolis (EEPs) were tested against 69 clinical
strains isolated from C. albicans. Most of the EEPs showed satisfactory activity and eradication of the biofilm formed by C. glabrata and C. krusei on the surfaces of polyvinyl chloride
and silicone catheters. The EEPs at the subinhibitory concentrations inhibited the morphological transformation of yeast into the mycelium of C. albicans in liquid medium and
mycelial growth in solid medium, respectively. An additional effect was observed when the
EEPs were combined with fluconazole and voriconazole against C. albicans [65].
In another study, the action of the hydroalcoholic extract of commercial propolis (20%;
Brazil) against strains of C. albicans isolated from patients with human immunodeficiency
virus and oral candidiasis was compared with the inhibitory action of the synthetic antifungals as nystatin, clotrimazole, econazole, and fluconazole. No difference was found between
the results of propolis and nystatin, whereas better results were observed for propolis than
for the other antifungals [66].
220 Natural Oral Care in Dental Therapy
Regarding propolis products in the dental area, it has been observed that their performance is related to the control of denture stomatitis, a chronic infection caused by the
excessive proliferation of Candida species [67]. Due to the peculiarities of this strain and
the ability of this biofilm to adhere to the tissues and surfaces of dental prostheses [68], this
condition has a high prevalence among the elderly population and in individuals who do
not adequately clean these surfaces [67].
With regard to hygiene, it is known that the combination of mechanical and chemical
methods of denture cleaning is more effective than the isolated mechanical method [69].
In this sense, in the search of sanitation methods that cause less surface changes such as
abrasion and porosity, propolis products have been used due to their antifungal activity and
low influence on microbial resistance [35, 64].
In a randomized clinical trial, Brazilian green propolis (2%) was evaluated to control prosthetic stomatitis in the elderly, and its effect was compared to miconazole gel
(2%). There were significant reductions in the colony-forming unit count of 70% in the
miconazole group and 25% in the propolis group [70]. In another study where the same oral
miconazole gel was evaluated, the efficacy of a gel (2.5%) and mouthwash (24%) composed
of Brazilian green propolis in patients diagnosed with prosthetic stomatitis produced a significant reduction or complete remission of (p > 0.05) and significant reduction of Candida
colonies for miconazole oral gel, propolis gel and propolis for mouthwash, but without
difference between the treatment groups (p > 0.05) [71].
In another study, patients received Daktarin (miconazole gel, Janssen-Cilag, USA) and
Brazilian propolis gel (3%), and were instructed to use the product four times a day for 1
week. The patients were again examined after treatment, and it was observed that the two
products tested caused complete clinical remission of palatal edema and erythema [72].
Despite significant progress in the applicability of propolis, the area of dental products is
still growing, being important to encourage innovation and development of new products
with the addition of natural products such as propolis, based on knowledge of its composition and therapeutic properties.
14.4 Other Biological Properties of Propolis
14.4.1
Anti-Inflammatory Activity
The association of propolis and chlorhexidine may improve the recognition of antigens by
monocytes, mildly activate the transcription factor nuclear factors kappa B, and increase
the bactericidal action of human monocytes against S. mutans [16]. In a clinical study, an
Indian propolis extract was used as an adjuvant to scaling and root planning in the treatment of periodontitis and showed promising results when assessed according to clinical
and microbiological parameters [73].
The flavonoids present in propolis are considered representative phenolic groups among
products of natural origin and are suggested to be associated with the anti-inflammatory
activity observed in propolis. Among these flavonoids, we can mention galangin, which
probably acts by inhibiting the enzyme cyclooxygenase (COX), which is responsible for
the formation of prostaglandins. The immune system is modulated by thymus activation
and inhibition of prostaglandin production, stimulating cellular immunity and promoting
Propolis Benefits in Oral Health 221
phagocytosis. Another flavonoid present in propolis is the caffeic acid phenethyl ester, which
boasts of anti-inflammatory activity to prevent the release of arachidonic acid from the cell
membrane, suppressing the activities of COX-1 and COX-2 enzymes [74]. Therefore, flavonoids act by modulating cells involved with inflammation, inhibiting the production of
proinflammatory cytokines, modulating the activity of the enzymes of the arachidonic acid
pathway, and modulating nitric oxide-forming enzymes [75].
14.4.2
Antioxidant Activity
In addition to its antimicrobial and anti-inflammatory activities, propolis contributes to
tissue reorganization and is a promissory product to be added to topical formulations
due to its antioxidant properties [19]. The high content of flavonoids and phenolic compounds are associated with antioxidant activity. Red propolis has the highest overall antioxidant potential when compared with the brown and green propolis types, and when
the extract is obtained by the phenol extraction method, a higher antioxidant activity is
observed [47].
However, the relationship of bioavailability of propolis and the continued use of its oral
administration is not well defined in the literature. In a study that used a brown propolis
extract for determining the bioavailability in mice, the investigators observed that the glucuronide metabolite of galangin was measurable at 5 min after management in the plasma
of mice. This result suggests that the galangin, present in the composition of the brown
propolis extract, is rapidly absorbed and metabolized, promoting adaptations in the first
line defense antioxidant system [76].
14.4.3
Anticancer Activity
Oral cancer can be treated conventionally by means of surgery, radiotherapy, and chemotherapy. However, due the disadvantages associated with these treatments, the literature
has detailed an increasing interest in natural products that can combat cancer and its side
effects, prevent them from occurring, and increase the lifespan and quality of life of affected
patients. Propolis is one of the natural agents that have been studied for these purposes, and
its antitumor action is attributed to its flavonoids [19].
It is suggested that the flavonoids found in propolis present antitumor action through
different mechanisms such as suppressing cancer cell proliferation via anti-inflammatory
action, reducing the cancer stem cell population, blocking specific oncogene-signaling
pathways, exhibited antiangiogenic effects, and modulating the tumor microenvironment
(Figure 14.7D). Good bioavailability through oral administration and its safety profile
make propolis an ideal adjunct agent for use in future immunomodulatory or anticancer
treatments [77].
14.5 Benefits for Oral Health and Applications in Dentistry
Laboratory studies and clinical trials with propolis in different presentation forms including spray, extract, mouthwash, gel, toothpaste, chewing gum, and tablet (Figure 14.8) have
demonstrated its positive effect against oral pathogens. However, the production of easy
222 Natural Oral Care in Dental Therapy
Figure 14.8 Tablets of red propolis. Personal file.
and fast tests is necessary to further evaluate the composition and quality of propolis before
widespread adoption by the industry.
In dentistry, propolis can be used in different ways; for example, it can be incorporated
into endodontic materials such as intracanal medications [31] or used for the healing of oral
surgical wounds, as irrigating solutions for the treatment of periodontal diseases [78, 79],
and for treatment of prosthetic stomatitis [70]. It further can be incorporated into chewing
gums [54], mouthwashes [80], or varnishes [81, 82] associated or not with fluoride for the
prevention and treatment of early stages of caries or in adhesive systems, restorative materials such as glass ionomer cement, or in the treatment of dentin hypersensitivity.
In addition to these multiple applications, the use of propolis in storage medium for
avulsed teeth has been highlighted, because it can increase the survival time of the cells of
the periodontal ligament [83–85]. In addition, due to the adhesion characteristics of resinous products, propolis has been employed in the pulp capping agent [86–89]. Another effect
that deserves to be highlighted is its action on recurrent aphthous stomatitis by helping to
stimulate the immune system [90, 91]. It is also observed that propolis has contributed to
the formation aiding osseointegration [92, 93].
Therefore, there exists a wide range of possibilities for propolis application in dentistry
and the use of products with propolis to promote oral healthcare [51]. Importantly, though,
biocompatibility should be considered to ensure safety during its clinical usage. This characteristic can be evaluated to determine the quality of formulations derived from the natural product.
14.6 Final Considerations
Even with the variability of the natural products and the different designs of studies found
in the literature, it can be affirmed that propolis has the potential to be used as complementary therapy in caries prevention, dental biofilm control, treatment of periodontal diseases,
control of fungal infections such as prosthetic stomatitis, surgical wound healing, pulpal
therapies, and restorative treatments when incorporated into materials such as glass ionomer cement or adhesive systems. However, one should know that its use may causes allergic
reactions in some patients, so it should be marked as contraindicated for patients with a
propolis allergy or allergy to any components resulting from beekeeping or bees.
Propolis Benefits in Oral Health 223
Despite the growing number of investigations about natural products, additional studies are still needed to assess the toxicity and mechanism of action of propolis, besides its
interactions with other drugs and its cost-effectiveness in comparison with commonly used
synthetic products and/or other natural products. In addition, it is necessary to control
the quality of these products so that they can be marketed with greater security and better
efficacy. For this, the prominent interest of the industry in natural products such as propolis
can favor its large-scale use, both regarding products for professional and commercial use,
thus promoting improvements in the oral health of different population groups.
Acknowledgment
This study was financed in part by the Coordenação de Aperfeiçoamento de Pessoal de
Nível Superior—Brasil (CAPES)—Finance Code 001. The authors thank Cássia de Mattos
de Lima for the elaboration of the schematic drawing.
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15
Grape Seed Extracts in Dental Therapy
Anusuya V, Ashok Kumar Jena and Jitendra Sharan
*
Department of Dentistry, AIIMS, Bhubaneswar, Odisha, India
Abstract
Grapes are one of the majorly consumed fruits worldwide. They are a rich source of polyphenols,
carbohydrates and fruit acids. The presence of polyphenols and flavonoids increases the medicinal
value of the grape products. Grape seed extracts are used in the dental therapy for its antioxidant,
anti-proliferative, anti-inflammatory, anti-apoptotic, cytoprotective effects and collagen-cross linking ability with proteins. Different levels of trials and studies are going on the applications of grape
seed extracts in the field of medicine. In dentistry, the application is quite less and more focused
on the restorative dentistry and cariology, and applications in the remaining fields have also been
tried in various disease conditions. Though there is a need for enormous studies, clinical trials, and
development, this chapter throws important insights into the various aspects of grape seed extracts.
Keywords: Grape seed extracts, polyphenols, proanthocyanidines, cross-linking agent, antioxidants, remineralizing agent, dentistry, cariology, anti-cancer effects
15.1 Introduction
Grapes are one of the oldest and majorly cultivated fruits around the world. The majority of
grapes are grown in vineyards and used for the production of wine. Next to wine production, a major portion of the grapes is used as table grapes, i.e., whole grapes for fresh consumption. Also, grapes are used in various forms like raisins, grape seed extracts (GSEs),
grape seed oils, extract of grape skins, etc. Medicinal applications of grapes are mainly due
to the presence of flavonoids in it. Grapes are a rich source of polyphenols, present next to
carbohydrates and fruit acids [1]. Polyphenols are of prime importance in its role as antioxidant, anti-proliferative, anti-inflammatory, anti-apoptotic, cytoprotective effects, and
collagen-cross-linking ability with proteins.
Grapes belong to the genus Vitis, which was first studied by Linnaeus in 1735. Different
species of Vitis originated from different parts of the world, among which Vitis vinifera is
one of the oldest variety used for winery and others, and is of European origin. Grape seeds
are eliminated as waste products from the wine industry. In grapes, seeds constitute about
*Corresponding author: vanusuya91@gmail.com
Durgesh Nandini Chauhan, Prabhu Raj Singh, Kamal Shah, and Nagendra Singh Chauhan (eds.)
Natural Oral Care in Dental Therapy, (229–258) © 2020 Scrivener Publishing LLC
229
230 Natural Oral Care in Dental Therapy
10% of the weight of the fruit [2]. During growth, they are a rich source of hormones, so
they contribute to the regulation of berry development and ripening. The seeds contain
proteins, lipids, carbohydrates, and phenolic compounds in various proportions depending
on the variety of the fruit. The phenolic compounds present in grape seeds are polyphenols,
are the important therapeutic content, which makes the grape seed extract possible to use in
medicine and dentistry. These phenolic compounds represent the third most abundant constituents in grapes [3]. They are mainly flavonoids including gallic acids, monomeric and
polymeric forms of phenolic compounds. GSE is known for its potent antioxidant properties that help in the protection against aging, disease conditions, and its anti-inflammatory
properties help in reducing inflammation [4]. The presence of proanthocyanidins (PAs)
in the grape seed extracts a natural cross-linking agent and strengthens the collagen fibers
of dentinal tubules [5]. Also, the biomimetic properties of proanthocyanidins help in the
biomodification of the dentinal structure, which in turn help in improving the mechanical
properties of tooth structure. Thus, the GSE is an evolving therapeutic agent for its various
applications in dentistry. The present chapter elaborates on the basics of GSEs and its use in
all the spectrum of dental therapy. The first half of the chapter explains about the basics of
GSEs, its biochemistry, properties, the method of preparation, and molecular mechanism
of biological actions, and the second half elaborates on the various uses of GSE in dentistry.
15.2 Part I: Basics About Grape Seed Extracts
Grape seed extracts (GSEs) are the crude extracts of various phenolic compounds and its mixture or concentrated extract of an individual phenolic component through chemical processing
of grape seeds to be used for different purposes. GSEs used in dentistry are preferably prepared
from the seeds obtained from the Vitis vinifera species. Because grape seed varieties belonging
to Vitis vinifera have the highest amount of flavonoids [6]. Flavon-3-ols are the most common
flavonoids present in grape seeds and occur in various forms including monomers, oligomers,
and polymers. The amount and type of phenolic compounds in the grape seeds are influenced
by various factors like the location of production, cultivar, season, and degree of maturation.
15.2.1
Components of Grape Seed Extracts
Phenolic compounds are the basic bioactive natural compounds found in the GSEs. Among
the wide variety of phenolic compounds, two groups are found in the GSEs, i.e., flavonoids
and phenolic acids. Flavan-3-ols, otherwise known as catechins, are the most predominantly
found flavonoids in grape seeds. Phenolic acids include various proportions of gallic acid
either in free form or esterified with flavonoids. Polymerization of these monomer compounds produces oligomer, dimer, and polymers [1]. Three types of flavan-3-ol found in
grape seeds are monomer, dimers, and trimmers, also in galloylated forms. The monomers
include catechin, gallocatechin, epicatechin, and epigallocatechin, etc. Catechins condense
into oligomeric procyanidins, i.e., dimers found in the seeds and polymeric compounds otherwise called as condensed tannins [7]. More than 14 dimeric, 11 trimeric, and 1 tetrameric
procyanidin were separated from the grape seeds, and highly polymerized procyanidins also
present in it. Nearly 55% of the proanthocyanidins in the GSEs consisted of ≥5 monomer
units [8].
Grape Seed Extracts 231
HO
HO
HO
HO
B
HO
HO
O
A
O*
R
C
HO
HO
HO
(a)
HO
(b)
Figure 15.1 Molecular structure of (a) catechin and (b) cyanidin.
Condensed tannins, commonly known as proanthocyanidins, are the essential constituent of grape seed extracts. This polymeric form is the active content for its cross-linking
property with the collagen fibers. The degree of polymerization affects the ability to crosslink. Condensed tannins are responsible for the organoleptic properties of wines. It adds to
the astringency of wines and grape juice that is felt as puckering sensation in the mouth just
after drinking. This is due to the precipitation of salivary proteins by the tannins [9].
15.2.2
Chemical Structure
The structure of PAs has been studied widely. The molecular structure of dimeric and trimeric PAs was studied using high-performance liquid chromatography (HPLC) analysis. It
consist of catechin and epicatechin units. Catechin is built upon the diphenylpropane skeleton; the three-carbon bridge (C6–C3–C6) between the phenyl groups is usually cyclized
with oxygen [10]. Figure 15.1a, b shows the chemical structure of catechins and cyanidin.
The catechins are present in both trans- and cis-configuration. Catechins have three rings
named A, B, C with five hydroxyl groups. Based on the R in the third position of the B-ring,
it could be either catechin or gallocatechin. Cyanidin has identical arrangements of five
hydroxyl groups with catechin, but there is presence of a central anthocyanidin C ring,
which is unsaturated. This unsaturated C ring, allowing conjugation, doubles the antioxidant potential of cyanidin [11].
Catechins polymerize into dimers and trimers. Polymerization occurs at the fourth
position of the central C ring. They are termed as the B-series and C-series, respectively.
The B-series includes B1, B2, B3, B4, and B5, and the C-series includes C1 and C2 in the
GSEs. Fuleki and Silva identified 11 monomers with the use of the reverse-phase HPLC
from the red grape seeds [12]. The degree of polymerization (DP) may reach up to 16
units [8].
Gallic acid (GA) structure is present in Figure 15.2 GA is, 3,4,5-trihydroxybenzoic acid,
one of the commonly found phenolic acids in the GSE. It occurs either in free forms or
in the form of esters. Both increases the efficacy of GSE in protecting the body from various oxidative damages. The amount and site of galloylation play an important role in the
cross-linking process [13]. Figure 15.3a to 15.3f shows the chemical structure of some commonly present procyanidins in GSEs.
232 Natural Oral Care in Dental Therapy
15.2.3
Types of GSEs
GSEs can be categorized into the following types based on the different factors and applications in dentistry.
Based on degree of polymerization:
a. Monomers include
• Catechins
• Epicatechins
b. Polymers include
• Dimers—dimeric procyanidins
• Trimers—trimeric procyanidins
• Tetrameric procyanidins
• Polymeric procyanidins—condensed tannins
Based on the molecular weight:
• PALM—Proanthocyanidin low molecular weight fraction
• PAHM—Proanthocyanidin high molecular weight fraction
Based on the Galloylation:
a. Non-galloylated species include
• CT—Catechin
• EC—Epicatechin
b. Galloylated species include
• EGC—Epigallocatechin
• ECG—Epicatechingallate
• EGCG—Epigallocatechin gallate
Based on the percentage of GSE mixtures
GSE mixtures include both monomers and polymers. Based on the percentage of the proanthocyanidin in the solution, it could be 2%, 5%, 10% weight of the resin adhesives.
Based on the percentage of GSE in the distal water diluent, it is used in 6.5%, 10%, 25%,
50% irrigant solution in the endodontic irrigants.
15.2.4
Methods of Separation
GSEs are prepared most commonly from the seeds of species Vitis vinifera. The preparation
of crude extract from grape seeds is explained below in the flow diagram.
HO
HO
COOH
HO
Figure 15.2 Molecular structure of Gallic acid.
Grape Seed Extracts 233
HO
HO
HO
HO
HO
O
O
OH
R
OG
HO
HO
HO
(b)
(a)
OH
OH
OH
OH
O
HO
O
HO
OH
OH
OH
OH
HO
HO
OH
OH
O
HO
O
HO
H
OH
HO
OH
H
OH
(c)
(d)
OH
OH
OH
OH
O
HO
O
HO
OH
OH
OH
HO
OH
OH
HO
O
HO
OH
O
HO
H
OH
OH
(e)
H
OH
HO
(f)
Figure 15.3 Molecular structure of (a) epicatechin, (b) epicatechin-3-gallate, G=gallic acid, (c) procyanidin
dimer B1, (d) procyanidin dimer B2, (e) procyanidin dimer B3 and (f) procyanidin dimer B4.
234 Natural Oral Care in Dental Therapy
Grapes (Vitis vinifera)
Manual separation of seeds
Washing the seeds (preferably with distilled water)
Drying process
(If air drying then storage at -30˚C until used / if sun drying then storage at room temperature)
Pulverization of stored seeds under liquid nitrogen (N2)
Extraction of powder (approximately 50 g) 2 times successively in acetone / water with
proportion 7:3 (under N2)
Removal of the plant debris by centrifuge
Evaporation of acetone under vacuum and freeze-drying of aqueous solution
Blending of the obtained extracts together (approximately 2.1 g and 1.3 g each)
Crude tannin extract (grape seed extract is ready)
The crude extract is ready for preparation of various forms of GSEs and separation
of polyphenols. Different polyphenols and procyanidins are fractioned from this crude
extract. The following methods are used for the fractionation and separation of various
constituents of GSEs.
•
•
•
•
•
High-performance liquid chromatography (HPLC) [12]
Reverse HPLC [14]
Gel permeation chromatography (GPC) [8]
Liquid/liquid extraction
Thiolysis monitored HPLC [15]
• Ultrafiltration [16]
In GPC, filtration helps to selectively separate the individual components based on the
molecular size. The selective removal of targeted components from the complex mixture
is called chemical subtraction. Chemical subtraction is done mainly by the method called
countercurrent separation, which specifically separates only the targeted components.
This method is further developed for selective enrichment or depletion of extracts and
coined as DESIGNER (Deplete and Enrich Select Ingredients to Generate Normalized
Extract Resources). Phansalkar et al. modified the DESIGNER CCS technique using centrifugal partition chromatography (CPC) [17]. The CPC was a reliable tool for the development of procyanidin-based dental biomaterials in dental application.
15.2.5
Factors Influencing the Quality and Quantity of Polyphenols in the GSEs
Polyphenols, being the third most abundant content in the grapes, are distributed in different amounts in the different parts of the grapes. Phenolic compounds are broadly distributed among the whole pulp, grape seeds, and the skin. The total extractable phenolics
are present around 10% in pulp and about 60–70% in the seeds. Skin phenolics contribute
around 28–35%. The total content of phenolics in seeds range from 5% to 8% by weight [18].
Production of polyphenols in the grapes depends on many factors. Quality and quantity of
Grape Seed Extracts 235
phenolic compounds vary depending on the grape variety. Total phenolic contents of table
grapes or seedless grapes are lower than the grapes used for winemaking. Likewise, the composition of phenolics in the red grapes is different from that of white grapes. The following are
the important agroecological variables that influence the total content of phenolics in grapes
such as cultivar, the climatic condition and site of production, and the degree of maturation.
The cultivar
The variety of grape seed from which the GSE is prepared affects the quantity of polyphenols in it. Kovac et al. analyzed about 19 cultivars of the winemaking grapes to compare
their phenolic contents in the year 1987 [19]. All the grapes were harvested at the same
time with the same stage of maturity. On analysis, the total content of phenolics varied from
414 mg/kg to 2,593 mg/kg of the grape. Pinot Gris and Pinot Noir, varieties belonging to
the Vitis vinifera, had the highest content of the catechins and procyanidins among the 19
cultivars studied. When comparing the table grapes with winemaking grapes, table grapes
contain a lower total phenolic content. The type of phenols also varies according to the cultivar. Fuleki and Silva studied the individual phenolic components and their variation in the
following varieties, vinifera, labrusca, and hybrid cultivars [12]. Compositional variation of
procyanidin dimers, trimers, monomers (catechins and epicatechins), and dimer gallates
were studied. Procyanidin trimers were found to be highest among the Pinot Noir variety
(red grapes). Monomers were found to be highest in the hybrid (Vincent) red grapes and
equally in the Pinot Noir variety [12].
Climatic condition and site of production
The quantity of individual phenolics in the grape seeds from Muscat of Hambourg was
studied by Revilla et al. [6]. It was found that the content of the phenolic was variable during
the period 1992–1993, in spite of the degree of maturity. Changes in the climatic conditions affect the production and maturation of phenolics in the seeds. Along with climatic
changes, the site of production and soil quality affect the quantity of polyphenols in the
seeds. Tempranilo grapes cultivated in different sites of Madrid in Spain had total content
of catechins and procyanidins from 108 to 225 mg/kg of grape.
15.2.6
Physical Properties of Polyphenols
The following physical properties of polyphenols are studied: molecular weight, solubility,
melting point, and optical rotation.
Molecular weight of the various polyphenols is given in Table 15.1. Molecular weights of
the monomer are based on their molecular structure, whereas the molecular weight differences in the polymers are based on the degree of polymerization [20]. This difference in the
molecular weight is the fundamental principle in the development of gel permeation chromatography and membrane fractioning of polyphenols. Also, the molecular size affects the
cross-linking ability of the GSE constituents with the dentin collagen and its stabilization.
The solubility of polyphenols is one of the important physical properties. Some phenolic compounds are water soluble and some are lipid soluble. Most of the monomers are
lipid soluble, i.e., catechin is lipid soluble, whereas procyanidins are water soluble. Thus,
the difference in the solubility helps in the easy separation of procyanidin from catechins.
Therefore, it is easy to prepare the water-soluble procyanidins by separating it without any
236 Natural Oral Care in Dental Therapy
Table 15.1 Various physical properties of the polyphenols.
S.no
Properties
Values
1.
Molecular weight (MW)
Catechin
Epicatechin
Epicatechin-3-o-gallate
Procyanidin dimer
Procyanidin trimer
Procyanidin tetramer
293
294
445
580
870
1160
Solubility
Catechin
Procyanidins
Lipid-soluble
Water-soluble
Melting point
Catechin
Epicatechin
Epicatechin-3-o-gallate
174°C
236°C
236°C
Optical rotation
Catechin
Epicatechin
Epicatechin-3-o-gallate
0°
58.3°
188°
2.
3.
4.
use of organic solvents. It adds more value and increases the safety of the food. This is one
aspect of solubility.
Another importance in the solubility of polyphenols is the role of polyphenols in
scavenging superoxide radicals and understanding its antioxidant potential [11]. Watersoluble procyanidins and lipid-soluble catechins, both follow different pathways of antioxidant mechanisms. In the aqueous phase, the antioxidant activity of procyanidins is
mainly due to its reducing activity in the o-dihydroxy structure. Whereas, polyphenols in
the lipophilic phase work by either of the following modes: (a) chelating the copper ion,
(b) hydrogen donors, and (c) regenerating alpha-tocopherol. Catechin lacking a carbonyl
group as well as a 2,3-double bond is relatively ineffective in the inhibition of oxidation
compared to procyanidins.
15.2.7
Biochemical Properties (Biological and Pharmacological) of
polyphenols
The characteristic biochemical properties of polyphenols are based on the ability to interact
with different molecules such as macromolecules like proteins and polysaccharides, metal
ions, and radical scavenging activities. Phenolic nuclei in the molecule are the principal key
structure for its physical and chemical properties. These properties play complete, partial,
or at least part of the role in their physiological and pharmacological actions. Among the
different biochemical interactions of polyphenols, the following three distinctive characteristics of polyphenols have been proposed as a mode of action for their biochemical interactions as a therapeutic agent.
Grape Seed Extracts 237
a. Polyphenol–protein interactions
b. Antioxidant and radical scavenging activity
c. Metal ion complexation
a. Polyphenol–Protein Interactions:
Various biological activities of polyphenols as medicinal agents revolve around the interaction between the protein and polyphenols, and protein binding. The puckering sensation/
astringency felt just after the intake of grape juice or wine is due to the precipitation of salivary
glycoproteins by tannins [21]. Antioxidant activities, anti-inflammatory, and cytoprotective
effects are dependent on the biological efficiency and interaction through different proteins in
the body. In turn, the biological efficiency of polyphenols mainly depends on the bioavailability, which is influenced by one of the important factors, i.e., protein–polyphenol interaction.
The application of GSEs in conservative dentistry is based on the collagen-stabilizing
property. The molecular basis of this property is the interaction between polyphenols
and protein. Protein–polyphenol interaction is fundamental for its application as a biomimetic agent for desensitization, as a cross-linking agent in adhesives, in improving the
mechanical properties of the dentin and root structure, reducing the demineralization,
and as a collagen-stabilizing etchant. The propensity of polyphenols to bind with proteins
also accounts for the ability to inhibit various enzymes such as glucosyltransferases of
Streptococcus mutans [22].
Polyphenols interact with proteins in a reversible and irreversible manner. Generally, in
solution, an initial reversible interaction occurs between protein and phenol that produces
soluble protein/tannin complexes until it reaches equilibrium. These soluble complexes
may keep increasing in size, which no longer could be soluble and may aggregate or starts
precipitating. This may still be in the reversible form, which redissolves or further undergo
different processes, i.e., oxidation reaction with metal ions leads to irreversible precipitation of complexes [23]. The precipitation ability of polyphenols differs with respect to the
different varieties of proteins. It was found that the relative affinity of condensed tannins
varied more than 1,000-fold. The highest affinities were found for proteins, polymers rich in
proline content, i.e., proline-rich proteins (PRP), and polypeptides, and the lowest affinity
was found for small globular proteins like lysozymes. It has been found that large proteins
with high proline contents and with lack of secondary or tertiary structure are readily precipitated by tannins.
The polyphenol–protein complexation is specifically a molecular recognition phenomenon. The principle of molecular recognition in the complex formation is mainly of
“hand-in-glove”. We need two sites for the complex formation, a donor molecule, and an
acceptor molecule. In the hand-in-glove type, matching between the receptor and ligand
is a dynamic process and also a time-dependent one. Both the molecules are mobile and
flexible; thus, they acquire different shapes as complexation proceeds [23]. This complex
formation is dependent on molecular size, protein type, pH, water solubility, composition
and conformational flexibility of polyphenols. Table 15.2 outlines the different facets of the
polyphenol–protein interaction.
Hydrophobic Effects:
Solubility in water is an important factor in polyphenol-protein complexation. Presence of
hydrophilic groups on molecular surfaces, i.e., hydroxyl groups on polyphenols, and carbonyl
238 Natural Oral Care in Dental Therapy
Table 15.2 Facets of the polyphenol–proteins interaction.
S. no
Different facets
1.
Polyphenol–protein complex formation is a time dependent, dynamic surface
phenomenon. Structural flexibility of both the molecules is important in the
interaction. The molecular recognition is mainly “hand-in-glove” type. Unless
further reactions take place, the primary interaction between protein and
polyphenol is reversible.
2.
Affinity for polyphenols is a highly variable factor. Small, compact proteins have
very poor affinity whereas proteins with more open structure such as proline-rich
proteins, gelatin, salivary proteins have high affinity toward polyphenols and make
much stronger interactions.
3.
Phenolic nuclei and presence of aromatic ring provides multidentate ligands to
protein structure. Thus the molecular size of the phenolic group is important and
the galloylation increases the efficacy of pholyphenol–protein complexation, i.e.,
tri < tetra < penta. Molecular size and galloylation are directly proportional to the
binding efficacy.
4.
The energetics of the complexation is mainly associated with “hydrophobic effects”
followed by reinforcement via “hydrogen bonds”.
and amide groups on peptides are responsible for solubility. The degree of solubility is approximately proportional to the availability and proximity to the hydrophilic groups, where water
molecules are anchored between the donor and acceptor. Reorganization of water molecules
drives the complexation process to takes place. Hydrophobic effects in the polyphenol–protein
complexation are due to the presence of complex species of groups or regions that are hydrophobic in nature. Hydrophobic forces drive these structures in the various molecules to
aggregate together and form the complex. The hydrophobic forces are contributed by van
der Waals forces and the complex is stabilized further by the entropic effect. It is believed that
aromatic rings of polyphenols and carbon-hydrogen skeleton of proteins provide multiple
hydrophobic sites to participate in such interactions. So, if the polyphenol is highly water
soluble then the formation of the complex with protein is less likely to take place. Thus the
polyphenol/protein affinity is in an inverse relationship with its water solubility. Addition
of chemical molecules, other substrates, or inorganic acids that alters the polyphenol’s
solubility could be used to change the range of polyphenol–protein complexation [24].
Hydrogen Bonding:
Hydrogen bonding plays a second key role in the protein complexation. Direct functionality, and presence of multiple hydrogen bonding sites in polyphenols, enhance the overall strength of the hydrogen bond that stabilizes the complex. In this process, molecular
recognition occurs through the deployment of hydrogen bonds in water due to the interaction between solutes and forces of solvation. The potential hydrogen bonding groups in
the substrate are also usually the water-soluble groups. So, they readily participate in the
aqueous medium. Thus, for the hydrogen bonding in protein-polyphenol complex to take
place, first, the hydrogen bonds formed by both polyphenols and proteins with the water
must be broken. The overall energetics of interactions depend on the stability of hydrogen
bonds, which are broken and made.
Grape Seed Extracts 239
Carbonyl groups in the tertiary amides are much more effective in accepting the hydrogen bonding than those in the primary and secondary amides. Along with it, the methylene substituents of tertiary amide nitrogen readily donate the electron into the peptide
bond, making it to be an electron-rich site. Thus, the carbonyl group has a higher capability for accepting the hydrogen bond. Hydrogen bonding networks are deployed and
formed between the proton donors and proton acceptors (phenolic hydroxyl groups of
polyphenol–proton donors and carbonyl groups of prolyl peptides-proton acceptors) [25].
b. Antioxidant Activity:
In recent years, accumulation of toxins and oxidative damage leads to disease conditions and
their pathophysiology has taken much attention. Considerable interest of medicine into the
natural antioxidants is increasing day by day. Natural antioxidants are found in fruits, vegetables, green tea leaves, and seed oils. The polyphenolic flavonoids are the potent antioxidants
[11]. Though the majority of the flavonoids that are consumed come from tea, wine contributes a considerable amount. The French paradox is a good example of the importance of natural antioxidants in the diet and reduction in coronary heart disease (CHD) [26]. Excessive
dietary fatty acids undergoing lipid peroxidation, oxidative accumulation from pathogenic
bacteria, and inflammatory process lead to further damage and progression of diseases.
In cellular prooxidant states, reactive oxygen species concentration in the intracellular
compartment is increased. This may be due to excessive production or reduced ability to
eliminate them [27]. The reactive oxygen species are the activated form of oxygen via reduction of oxygen that produces superoxide radical O−2 . The major source of electrons is being
leaked from the various electron transport chains in the intracellular components. Thus, the
superoxide radical is formed in almost all the aerobic cells. In the aqueous medium, there is
spontaneous dismutation of the superoxide radical into hydrogen peroxide formation. The
superoxide dismutase enzyme accelerates the reaction. Further, it converts into a highly
reactive hydroxyl radical. The oxidative damage occurs mainly due to hydroxyl and hydroperoxyl radicals. However, the less active superoxide and hydrogen peroxide are important
because they can diffuse into remote cellular locations and cause distant damages.
Other important activated species are reactive nitrogen species (RNS). It includes nitric
oxide (NO) radicals and nitrogen dioxide radicals. NO have high affinity toward O−2 radicals, and the reaction between them produces a highly reactive molecule ONOO−. The
highly reactive molecule formed, initiates the process of lipid peroxidation, eventually
give rise to lipid hydroperoxide [28]. Oxidative stress arises when there is disturbance
in the prooxidant/oxidant balance. Normally, cells have its defensive antioxidant mechanisms to remove the reactive molecules either endogenously or by dietary supplements.
Polyphenols are known to inhibit the lipid peroxidation and lipoxygenases in-vitro, and
they have the ability to scavenge the hydroxyl, superoxide, peroxyl, and nitric oxide radicals. Epidemiological data indicate that the consumption of food items rich in polyphenols
increases the plasma antioxidant potential [29]. It was found that red wine contains up
to 4 g/L of phenolics, mainly flavan-3-ols, oligomeric procyanidins, and anthocyanidins,
and the regular consumption of red wine could reduce the incidence of CHD. Antioxidant
activity of proanthocyanidins is superior to vitamin C and vitamin E. One thousand times
diluted concentrations of PA from wine extracts were better than vitamin C and E in inhibiting lipid oxidation [30]. The assay of antioxidant potential is measured as total antioxidant
activity (TAA) or Trolox equivalent antioxidant activity (TEAC). It could be defined as the
240 Natural Oral Care in Dental Therapy
concentration of Trolox solution with an equivalent antioxidant potential to a standard
concentration of a compound under investigation [11].
c. Metal Ion–Complexation:
Tannins produce a blue-black color when treated with iron salts. It has been noted that the
property of natural polyphenols with catechol nuclei forming strong complexes with metal
ions such as iron, manganese, and calcium, etc., is important. When concerning the with
iron, it is well known for its role in redox reactions, effect on microorganisms, iron balance
in the body, and in iron-deficiency diseases. The antimicrobial activity of polyphenols over
siderophore producing Escherichia coli occurs through iron depletion [31]. Likewise, the
chelation of polyphenols with calcium ions produces the precipitation and deposition of
minerals over dentine that acts as a scaffold for the remineralization process. It is one of
the important applications in the reparative and therapeutic approach of the dental caries.
Biocompatibility and Cytotoxicity of Polyphenols:
PAs and other components of GSE are much more biocompatible than other synthetic components. As a natural derivative, and as the source is dietary in origin, it is well tolerated at
high doses. The pharmacological actions of PAs are better at high doses.
Majority of GSE application in dental therapy is on the prevention and repair of dental
caries in vital teeth. GSE must be compatible with the pulpal tissues. Dose-response and
time-response of pulpal cells for GSE were found to be biocompatible [32]. The lowest concentration was 0.0065%, and the highest tested was 6.5%, and direct and indirect contact
tests were assessed. At the lowest concentration, an increase in cellular metabolism and
increase in the extracellular matrix synthesis were found in the direct contact test. The
highest cell viability was observed at both the concentrations. In the indirect contact test,
the dentinal barrier was used. At a concentration of 0.65%, the viability of cells were maintained with an increase in cellular metabolism. Both the tests revealed no time-dependent
response when performed at 24 to 72 h duration.
15.3 Part II: Biological Applications in Dentistry
Grapes seed extract is used as a therapeutic agent in medicine for its known benefits. The
presence of polyphenols in the GSEs is one of the important biologically active constituents
of GSE increases in its medicinal values. Table 15.3 outlines some of the pharmacological
and physiological actions of polyphenols. The characteristics of polyphenol such as protein complexation, metal ion complexation, and cross-linking of collagen make it possible
to apply in various dental therapies. GSE application in dentistry and dental therapy was
explained under different headings based on its uses in the different branches of dentistry
for the convenience of understanding.
15.3.1
GSEs in Dental Caries
The study about the development of dental caries, its prevention, and therapeutic technique is called cariology. During the process of dental caries, chronic destruction of the
tooth structure takes place by demineralization of inorganic and degradation of organic
Grape Seed Extracts 241
Table 15.3 The pharmacological and physiological actions of polyphenols.
S. no
In food industry
a.
Palatability
b.
Astringency
c.
Nutritional value
d.
Helps in ageing in winery
In Medicine
a.
Antioxidants
b.
Anti-inflammatory
c.
Anti-carcinogenic
d.
Cross-linking activity
e.
Antibiotic
f.
Cytoprotective effect
g.
Anti-mutagenic by directly inhibiting the mutagens
In Dentistry
a.
Cross-linker
b.
Remineralizing potential
c.
Anti-erosive capacity
d.
Antiplaque activity
e.
Antibacterial, both bactericidal and bacteriostatic
f.
Dentin biomodification
g.
Anti-carcinogenic against oral cancer cells
h.
Endodontic irrigant
i.
Therapeutic drug In periodontitis
parts of the tooth. Dentin occupies the major portion of the tooth and is composed of
inorganic minerals, organic matrices, and water. The collagen matrix comprises about 30
vol %, in which 90% are type I collagen, and 10% are non-collagenous substances. In the
caries process, demineralization, i.e., dissolving the mineral, occurs via acids that expose
the collagen to destruction by bacterially derived enzymes and also by host-derived
enzymes. After demineralization, if protected, the collagen matrix will act as a major scaffold for remineralization and plays an important role in remineralization of carious dentin. Fluoride is a well-established remineralizing agent, which prevents and inhibits caries
lesions. Fluoride forms flouro-hydroxyapatite crystals, which are more resistant to acid
242 Natural Oral Care in Dental Therapy
attack [33]. Thus, the ideal approach in prevention and reduction of caries progression
especially root caries should be focused on the use of substances that alters the dentin
matrix to promote remineralization, and prevent and resist organic matrix degradation.
Recently, various products have been investigated for its antibacterial and remineralizing potential on teeth. Grape seed extracts are used as a natural cross-linking agent that
strengthens the dentin organic matrix, and it is also an effective bacterial enzyme inhibitor. The application of GSE in cariology could be divided into those in the prevention of
dental caries and those in the reparative therapy of dental caries, which is covered under
the topic of GSEs in conservative dentistry.
Prevention of Dental Caries
Grape seed extracts are used in the prevention of caries by acting on the various stages of
caries development. GSE prevents enamel erosions by reducing mineral loss and enhancing re-uptake, antiplaque effect by inhibiting the adhesion of biofilm, antibacterial activity
against S. mutans, and degradation of collagen matrix with improvement in the quality of
dentin through biomodification. GSEs are used in the prevention of dental caries by the
following activities.
•
•
•
•
•
15.3.2
Anti-erosive agent
Antiplaque agent
Antibacterial agent
Biomodifier
Reminearlizing agent
Anti-Erosive Agent (Prevention of Enamel Erosion)
Enamel is the hardest part of the tooth with 90% of the minerals in the form of hydroxyapatite crystal and the remaining are organic portions and water. These minerals readily
dissolve in the acidic environment with a critical pH of <4.5. The erosive pattern of enamel
demineralization is different from dentin demineralization. Erosion is the process of tooth
structure loss by a chemical process without the involvement of bacteria. Destruction
occurs mainly due to the exposure of dental structures to acids, either extrinsic or intrinsic.
Extrinsic sources such as occupational exposures and acidic beverages generally cause erosion on the labial surface. Whereas, intrinsic sources of acid are from the reflux of gastric
acid into the oral cavity due to conditions like anorexia nervosa, gastroesophageal reflux
disease, and bulimia. Intrinsic sources generally cause erosions of the enamel on the palatal
and lingual surfaces of the teeth.
Prevention of enamel erosion is mainly by increasing the acid-resistant crystal formations in the enamel. Remineralizing agents such as fluorides, bioactive glass, and casein
phosphopeptide–amorphous calcium phosphate (CPP-ACP) are used to produce strong
hydroxyapatite crystals. GSE has been studied to evaluate the ability to reduce enamel erosions. Nandakumar and Nasim comparatively evaluated in vitro the GSE and cranberry
extracts in the prevention of enamel erosion [34]. The evaluation was done using optical
emission spectrometry, and stannous fluoride was taken as the control. The erosion remineralization cycle used was the immersion of enamel slab for 10-s in 20 ml of HCL, then
60 s in 20 ml of artificial saliva, then 30-s exposure to 20 ml of respective remineralizing
Grape Seed Extracts 243
solutions followed by 60-min immersion in artificial saliva. After three erosive challenges,
the amount of mineral loss was assessed through optical emission spectrometry. Exposure
to 0.65% w/v solution of GSE for 30-s, considered as the minimal concentration of GSE
required to produce remineralization, produced a remarkable amount of remineralization.
The possible mechanism for the remineralizing effect is through superficial mineral
deposition over the enamel lesion by formation of insoluble complexes. Mirkarimi et al.
found that after treating with GSE solution, there was scaffold formation on the surface of
the enamel with cluster-like structures resembling initiation of the remineralization process [35]. Prevention of enamel erosion is more of a metal–ion complexation process than
decreasing demineralization. Though the GSE solution was producing remineralization,
compared with the gold standard stannous fluoride, the effect was inferior. There were no
significant or comparable results of GSE solution with stannous fluoride in enamel remineralization. However, GSE is more effective in the prevention of enamel erosion. When the
effects on artificial enamel caries of primary teeth were studied, GSE had positive effects
in vitro on the remineralization of enamel caries lesions. Both in permanent and primary
caries prevention, GSE could be an effective non-invasive modality to treat caries.
15.3.3
Antiplaque Effect
Dental plaque is a biofilm formed on the tooth surface and other structures of the oral
cavity. It is the major etiological factor for oral diseases such as dental caries, gingivitis, and
periodontitis. It is tenaciously adherent, gelatinous microbial colonies with hundreds of
diverse species within this ecological niche. Microbial composition varies periodically and
depending on the location in the oral cavity. However, it is clearly found that in the progression of plaque, streptococci are the predominant species, which pioneer the plaque formation, followed by actinomyces, and later with the mature colonies of gram-negative bacteria.
Thus, an effective antiplaque agent works at different levels of biofilm such as anti-adhesive,
preventing the bacterial cohesions, reduction in the growth of microbial colonies, and bactericidal effect.
The distinct step in plaque development is the formation of a condensed layer of salivary
pellicle at the base of the dental plaque. This pellicle serves as the receptor site for binding
of various bacteria. Among the streptococci groups, two groups are important in the formation of plaque. One is S. sanguis and the other is S. mutans [36]. Though S. sanguis is the
pioneer in the attachment of plaque, S. mutans is the major etiological agent in caries and
other oral diseases. Thus, kinetics of oral bacterial adhesion and the adherence characteristics of S. mutans were the subjects of interest.
Inhibition of Adhesion:
Microbial adherence is the essential step for plaque formation. Gibbons suggested two processes of bacterial adhesion to the tooth surfaces. The first one is adsorption of the cells to
the pellicle, and the second one is the binding of cells to each other to further building up
of plaque. S. mutans bacteria are meant for its production of insoluble glucans that helps
in binding of cells. Glucosyltransferases, which are produced by S. mutans, polymerize the
glucosyl moiety from sucrose and starch carbohydrates into glucans. The insoluble glucans,
alpha-1,3 branched glucans produces the cohesion of bacteria. Thus, controlling the bacterial adhesion by interfering these processes would be a better mode of antiplaque activity.
244 Natural Oral Care in Dental Therapy
Major components of grape seed extracts are condensed tannins, which are composed
mainly by different polyphenols. Polyphenols are well known for their interactions with
proteins. One of the key characteristics of polyphenols for its biological activity is the ability
to interact with proteins and form protein–polyphenol complexes. This complexation produces different effects in different ways depending on the type of protein–polyphenol complex. Polyphenol interaction with salivary proteins precipitates them, which produces the
astringency of wine. While polyphenol binds with plasma proteins, then the bioavailability
of polyphenols is reduced. Likewise, polyphenols bind with peptide enzymes and deactivate
them. This important biochemical property of polyphenols is used to selectively inhibit
unwanted enzymes and break their biochemical cycle.
Polyphenols from the GSE binds with glucosyltransferase (GTF) enzyme and inhibits
its action. Thus, the synthesis of insoluble glucans is inhibited, and biofilm formation
is disturbed. This is the expected basic mechanism of action in the use of GSE as an
antiplaque agent. GSE effects on GTF activity has been studied in vitro separately or in
combination with Fluorinol (3-pyridinemethanol hydrofluoride) [37]. GSE separately
inhibited the GTF by about 43.9%. When combined with the Fluorinol, the inhibition
was more with 65.7% for the initial overall reaction. After 24 h of observation, the inhibitory activity did not improve significantly. It suggested the contribution of GSE in the
inhibition of GTF that majority was done by GSE in the initial reaction itself. Biofilm
inhibition and antibacterial activity of GSE is explained in the following sessions, which
also contribute mainly to the antiplaque effect. Thus, GSE acts in multiple ways to reduce
the plaque activity.
15.3.4
Antibacterial Agent
GSEs also have antibacterial activity along with antiplaque activity. It was found that minimal
inhibitory concentration (MIC) and minimal bactericidal concentration (MBC) values were
high for GSE. MIC is the concentration at which no bacterial growth was visible after 24-h
incubation at 37°C. MBC is the concentration at which the CFU number was reduced by
99.9%. The MIC value of GSE against S. mutans was 2 mg ml−1 and the MBC was 4 mg ml−1.
Antibacterial effect of GSE reduces bacterial growth and biofilm formation. This accounts for
the combined mechanism of antiplaque agent along with inhibition of glucosyltransferase
enzymes. Biofilm assay was done to measure the antibacterial efficacy of GSE. After 64 h of
incubation, the biofilm formation from the dental plaque sample produced around 33.6 ±
2.1 µm. When exposed to 2 mg ml−1 of GSE, a significant decrease in the microcolonies was
observed with biofilm thickness 17.9 ± 3.2 µm. Considering the concentration of GSE used,
it was found that the most successful concentration for inhibiting the biofilm is 2 mg ml−1,
above which its effectiveness decreases due to the poor dissolution in water [37].
The procyanidin fraction of the polyphenols was the most active antibacterial component
than other fractions, with MIC value against the S. mutans of 1.0 mg ml−1. Table 15.4 outlines
the MIC values of procyanidin against different species [38]. Milan Swadas et al. comparatively tested the antimicrobial activity of GSE at various concentrations against the chlorhexidine gluconate by measuring the number of colony-forming units. GSE with concentrations
500 mg/mL and 250 mg/mL had an antibacterial effect on the S. mutans colonies, but they
were not superior or equal to 2% chlorhexidine gluconate [39]. Apart from S. mutans, another
important bacteria studied was A. actinomycetemcomitans ATCC 43718.
Grape Seed Extracts 245
Table 15.4 MIC values of procyanidin against different species.
S. no
Microorganism
MIC values, mg ml−1
1.
Candida albicans
>64
2.
Enterococcus faecalis
32
3.
Escherichia coli
32
4.
Pseudomonas aeruginosa
32
5.
Aggregatibacter actinomycetemcomitans
4 (3.84)
6.
Streptococcus mutans
1
7.
Streptococcus oralis
0.25
8.
Streptococcus salivarius
0.25
9.
Streptococcus sanguis
0.25
10.
Lactobacillus acidophillus
0.25
The antioxidant activity of GSE also provides an additional benefit while used as an antiplaque agent. Generally, antiplaque agents are used in the form of mouthwashes. The availability of GSE to scavenge the superoxide radicals produced by plaque bacterial colonies helps in
the reduction of the damage and inflammatory reaction from the gingivae and periodontium.
15.3.5
Biomodifier
The biomimetic approach increases the quality of dentin structure by improving the
organic and inorganic portions of tooth material to resist the process of dental caries
along with enhancing the mechanical properties of the bio-improved microstructure of
tooth. We saw that the caries process of enamel and dentin differs totally because of the
difference in the composition of both. Dentin is composed of a more organic matrix relatively, which makes it important to improve and strengthen the collagen matrix, which
will resist degradation as well as act as a scaffold for remineralization. The root caries
is the same as that of dentinal caries in its progression, and it is difficult to approach to
restore. The early involvement of pulp due to its proximity leads to prevention is it to be
the best approach for root caries management. Prevention is possibly the best when there
is inherent resistant of dentin to the bacterial acidic and enzymatic damage. Therefore,
improving the mechanical and biochemical properties of the organic and inorganic constituents of dentin is a much evolving field and is an area of interest in the biomimetic
approach.
Dentin biomodifiers are natural or synthetic agents, used in the biomimetic approach
to enhance the mechanical properties, decrease the biodegradation rates, and promote the
remineralization of dentin [40]. The bioactive constituent of GSE is the basic catechin components scavenging the free radicals, which are required for calcium absorption. The PAs
increase collagen synthesis and accelerate the formation of insoluble collagen by conversion; thus, they decrease the enzymatic degradation of organic matrices.
246 Natural Oral Care in Dental Therapy
Pavan et al. studied (in vitro) the root dentin biomodification of GSE (Proanthocyanidins)
and the effects on the demineralization using microradio analysis [41]. This study showed
the direct effects of PAs on the root dentin. They compared the use of GSE alone and along
with fluoride, the standard remineralizing agent. The following facets are the role of GSE in
the biomimetic approach:
• GSE when applied alone, reduces the progression of root dentinal caries, but
compared to fluoride (F), i.e., the standard remineralizing agent, a lower scale
of reduction of caries was found.
• When combined with F, the GSE + F combination was better than the GSE
alone, but the expected initial fluoride deposition on the surface of lesion is
not allowing the GSE to effectively work.
• GSE improves and maintains the integrity of the dentin matrix, which is
comparable to the inner carious layer, thus, promoting remineralization and
decreasing demineralization.
• Mechanical properties of collagen matrices are modified by GSE, thus,
improving the properties and reducing the degradation of collagen.
• Formation of hydrogen bonding is the possible primary mechanism of PA to
interact with collagen and improve insoluble collagen conversion.
• Collagen–collagen interaction force was increased in the demineralized
dentin matrix after treatment with GSE having PAs of >94%. There was an
eightfold increase in the interaction force in the GSE-treated group, with glutaraldehyde having only 1.7-fold increase [42].
• GSE may also reduce the digestibility of collagen by interfering with various
bacterial enzymes and proteases.
• GSE binds to collagen via calcium (Ca2+) present in the remineralizing solutions that enhances the remineralizing process.
• GSE is a potential MMP inhibitor, which prevents the release of non-collagenase
proteins associated to the collagen fibrils of dentin, leading to inhibition of MMP.
• The inhibition of NCP cleavage by GSE prevents further matrix degradation
by protecting the collagen fibers [43].
• Antibacterial effects of GSE cannot be completely omitted in the reduction
of root caries, but it accounts very minimal or secondary with respect to biomimetic approach.
• GSE increases the modulus of elasticity of the dentin after treatment with
crude extract containing 80% total polyphenol content, and the rate of biodegradation is reduced from 77% to 10%.
• The ultimate tensile strength (UTS) of dentinal tubules increased with the
6.5% GSE treatment. The orientation of tubules significantly altered the UTS.
Tubules oriented parallel to tensile forces had less UTS than those oriented
perpendicular [44].
• After GSE treatment, the UTS of dentinal tubules reached about 15–20 MPa
depending on the dentinal tubule orientation.
• GSE treatment significantly increased the denaturation temperature (Td) in
turn, it signifies the degree of cross-linking and increased stability of the biomodified matrix.
Grape Seed Extracts 247
Liu and Wang determined the efficacy of the proanthocyanidins in stabilizing the dentin
collagen against enzymatic degradation [45]. Different concentrations of solutions in weight
percentage were tested against collagenase digestion following 1 h and 24 h. It was found
that application of ≥2 wt% of PA for 30 s provides the optimal protection for dentin collagen,
and also, the collagen was not digested significantly regardless of the digestion time. Zhao
et al. supported the same with a GSE concentration ≥2 mg/mL significantly inhibiting the
enamel caries lesion depth and mineral loss.
Fawzy further improved the mechanical properties by adding GSE into a nanoparticle delivery system [46]. GSE-loaded nanoparticles were synthesized by nanoprecipitation,
and loading was done into the biodegradable polymer poly-[lactic-co-glycolic acid] (PLGA)
nanoparticles. Loading was done at the PLGA/GSE (w/w) ratios of 100:75, 100:50, and 100:25.
Among the three ratios, sustained gradual release of GSE over 28 days with high cumulative
release was found in the 100:75, approximately 2.47 mg. However, the drug release kinetics
was similar in all. When it comes to resistance to biodegradation, significant increase in the
surface mechanical properties was found when treated with the PLGA/GSE ratio of 100:75
even after a long storage time (1 month and 3 months). Drug-loaded nanoparticle size should
be kept ≤200 nm to facilitate delivery into the dentinal tubules. Although there are possible
proposed mechanisms of delivery of nanoparticles into the dentinal tubules, the PLGA/GSEloaded nanoparticles’ mode of delivery into the dentinal tubules needs to be studied further.
15.3.6
GSEs as a Remineralizing Agent—Existing Dilemma
Facets of the biomimetic approach partially explain the role of GSE as a remineralizing
agent. Polyphenols produce metal–ion complexation with various metals, which is one of the
important modes of action in its pharmacological activity. The working principle is the same
in case of enamel and dentin remineralization, along with collagen interaction of dentinal
organic matrices. However, when talking about the efficacy of GSE as a remineralizing agent,
different studies have given different results. When compared with the existing remineralizing
agents, some studies found GSE to be superior to other agents, and some studies found it to
be equal or less effective to use for remineralization. Benjamin et al. found significant difference in the remineralization of GSE compared to fluoride (F) and calcium glycerophosphate
(CaGP). They compared 6.5% (w/v) GSE against 0.05% CaGP + 0.17% F, 0.5% CaGP and
deionized water using confocal laser scanning microscopy (CSLM). It was found that relative
optical density (ROD) for the GSE group was 78.37 and 45.32, 41.52 and 44.08 for others,
respectively [47]. Jawale et al. used the same concentrations of solutions, and posttreatment evaluation was done by polarized light microscopy (PLM). They found a significantly
small lesion depth and a wider mineral precipitation in the GSE group compared with the
other groups. The percentage of proanthocyanidin used was also mentioned, i.e., 98% [48].
Xie et al. evaluated the effects 6.5% GSE, 1,000 ppm Fluoride, and deionized water [49].
Posttreatment specimens were analyzed for microhardness test using Knoop hardness indentation (KHN), PLM image analysis, and CSLM analysis. KHN revealed no significant difference in the hardness of remineralized lesion with GSE and F. In the PLM, the lesion depth
was smaller in the F treatment group, and the mineral precipitation band was wider in the
GSE treatment group. CSLM analysis revealed that ROD was almost double in the GSE
group at 20 µm, 50 µm, and 80 µm with statistically significant difference. The ROD of the
GSE-treated sample at 50 µm was 73.23. Pavan et al. found that GSE is less efficient compared
248 Natural Oral Care in Dental Therapy
with the gold standard fluoride in the biomimetic approach. Though the GSE reduced the
progression of root caries lesion in vitro, the results were relatively less than fluoride [41].
15.4 GSEs in Restorative Dentistry
Two important uses of GSEs in the conservative dentistry are as a cross-linking agent and in
bonding of restorations and adhesives. Treatment of dental caries is mainly on the removal
of the infected enamel and dentin through cavity preparation followed by restoring it with
a biocompatible material.
15.4.1
GSEs as a Cross-Linking Agent
Successful dentin bonding depends on the formation and integrity of the hybrid layer.
After etching, the application of an adhesive on the exposed dentinal tubules made the
adhesive to penetrate and entangle with the dentinal collagen fibrils, thus forming a
hybrid layer. In the formation of achieving perfect seal and complete penetration of
the adhesive may not possible, which leads to the exposure of the dentinal collagen,
which in turn degrades over time. Exposed, unprotected collagen fibrils have relatively
less stability and mechanical strength. It reduces the bond strength and gradually leads
to bond failure. One specific approach to increase the resistance to degradation and
strengthen the exposed collagen fibrils is the use of cross-linking agents. Cross-linking
agents produce amino acid linkage between and within the molecules, thus, modifying and strengthening the collagen fibrils. Natural and synthetic cross-linking agents
are used for this purpose. Natural cross-linking agents are more preferable over synthetic for their biocompatibility and negligible side effects. Various natural cross-linking agents such as tannic acid, UVA-activated riboflavin, and polyphenol extracts from
plants are used.
GSEs are used as cross-linking agents for its high polyphenol content, improved overall
mechanical properties of dentin, and no cytotoxic effects on normal cells [32]. PAs produce the cross-links with the collagen of caries-affected dentin and reduce digestibility.
Compared to glutaraldehyde, GSE-treated dentinal collagens showed significantly more
resistance to digestibility by proteases [5]. PAs cross-link with collagen and mask the recognition sites for enzymes and/or retain the cleaved peptide fragments. Concerning the
bond strength, caries-affected dentin reaches near the bond strength of sound dentin after
treatment with GSE. It was found that 5% GSE inhibited the CTX release permanently. CTX
is the C terminal peptide released by cathepsin K degradation.
Potential benefits of GSE are
• GSE is a potential natural cross-linking agent with comparable results over
glutaraldehyde.
• Improvement in the mechanical properties depends upon the degree of
cross-linking.
• Inhibits the biodegradation of dentin collagen fibrils at the bonded interface
• Maintaining the dentin–resin bond strengths
• Biocompatibility even at high concentrations
• Antibacterial activity as an added benefit
Grape Seed Extracts 249
Current concerns of GSE includes
• Effect on the resin polymerization
• Depth of adhesive penetration may be affected
• Dentin discoloration and potential staining properties needs to be evaluated
on long term
15.4.2
GSE in Bonding
Application of GSE in bonding is based on the cross-linking ability of PAs to improve the
adhesive–dentin interface in bonding. The PA treatment on teeth could be in the form of
application as a separate step after etching, as a pre-conditioner, in the priming agent, in
the self-etch primer, in the adhesive, or as a PA-combined etchant. Application of the PAs
as a separate step after etching improves the tensile strength, decrease the collagen biodegradation of dentin matrix, and increase the bond strength. However, there is a need
of separate washing to remove the excessive PAs, and excessive stiffness of inter-tubular
collagen may restrict the depth of adhesive penetration. Transient application of PA-based
pre-conditioners increased the bond strength. The bond strength was increased in a timeand concentration-dependent manner [50]. Treatment with 15% PAs for 120 s was found to
best increase the bond strength. However, this application time of 120 s reduces the clinical
applicability. In spite of the long application time, the concentration used did not interfere
with the curing behaviors of adhesives [50].
GSE has been incorporated in the etchant to produce a collagen-stabilizing etchant.
The benefits of GSE in bonding would be better if it is in the adhesive itself. So adding the
GSE in self-etch adhesives reduces the need of multiple steps in bonding. However, the
scavenging activity of PAs in GSE limited the incorporation of GSE in the self-etch adhesives, as it is hampering the polymerization of adhesives to some extent. Thus, the addition of GSE in the etchant would reduce this effect. Combining the GSE with the etchant
will help in reducing the rinsing step, as both will be rinsed off together. However, when
the efficiency is considered, it was found that phosphoric acid concentration should
be maintained less than 20% [51]. As the collagen-stabilizing mechanism of PAs is not
dependent on covalent bonds, it was possible to combine the phosphoric acid and the
GSE, but the application of this combination on the polymerization of adhesive needs to
be investigated.
Cross-Linked Dry Bonding
Cavity preparations are followed by acid etching that produces microporosities in the
dentinal surface, which facilitate the infiltration of resin. The prepared cavity exposes
the mineralized healthy dentin, which has a modulus of elasticity (ME) of 20,000 MPa. The
processes of acid etching solubilize the crystallites to a depth of 10 um, leading to a reduction in modulus of elasticity. After etchant application, water rinsing is done to remove the
excess acid and solubilized minerals. Thus, the exposed mineralized dentin matrix has only
3–5 MPa of elastic modulus. In the wet condition, the collagen fibrils are very pliable, which
makes rapid interpeptide hydrogen bonds on dehydration. This leads to the formation of
a membrane-like structure, which is impermeable for the infiltration of adhesive resins
around the fibrils. To create a high resin–dentin bond strength by avoiding drying-induced
shrinkage, Kanca developed the wet-bonding technique [52]. This technique involves the
250 Natural Oral Care in Dental Therapy
wet demineralized dentin to float in 70% water during the monomer infiltration phase. This
technique again has the disadvantage of excessive residual water in bonds. Excessive residual water fuels the endogenous hydrolytic proteases that slowly degrade the dentin collagen
matrices. The goal is to replace the 70% residual water with resin infiltration during bonding, which is impossible with hydrophobic resin molecules.
Thus, the modified wet-bonding technique was developed to rectify all the problems.
Replacing the residual water by addition of a cross-linking agent will help to stiffen
the collagen as well as scavenge the residual water. We have seen the role of hydrogen
bond in the interaction of polyphenols and collagen peptides. The water is a known
hydrogen-bonding solvent. The presence of the water molecules do help in stabilizing the
protein–polyphenol complex, at the same time hindering the bonding between the adjacent collagen peptides. The balance between breaking the hydrogen bonds of the water
molecule and making the hydrogen bonds of the collagen peptides is the most important factor in GSE–collagen interaction. After etching, pretreatment with GSE allows
the dentin to completely air dry without collapse of the dentinal fibrils. The stiffness is
inversely proportional to shrinkage. Cross-linking the collagen with GSE allows the individual collagen fibrils to get separate from each other and also allows the penetration of
the adhesive. Five percent GSE pretreatment for 1 min allows the optimum cross-linked
dry-bonding technique [53].
15.5 GSEs in Endodontic Treatment
GSE is used in root canal treatment as an endondontic irrigating solution and in the postendodontic restorations.
15.5.1
Endodontic Irrigants
Root canal treatment includes three main steps, in which the most important step is cleaning and shaping. The aim of root canal preparation is to eliminate bacteria from the contaminated root canals and to provide the adequate shape to receive the final obturation by
cleaning and shaping. GSE shows antibacterial activity against many aerobic and anaerobic
bacteria. Among the different bacterial species, elimination of Enterococus faecalis from the
root canals during endodontic treatment is challenging. E. faecalis is a facultative anaerobic
Gram-positive bacterium and is isolated from about 67% of cases of endodontic failure and
about 18% of primary endodontic lesions.
GSE has been investigated as an endodontic irrigant for its antibacterial potential
and found that it poses good bactericidal efficacy against E. faecalis [54]. When used
with mechanical cleaning instruments such as ProTaper Next and Reciproc R25, it
reduced 96% of the bacteria with no significant difference in the reduction compared
to NaOCl and Ca(ClO)2. PAs in the GSE damage the microbial cells by altering the
selective permeability of the membrane, causing leakage of the essential intracellular
substances. An endodontic irrigant should be able to eliminate the bacteria, should have
bactericidal activity, able to penetrate the dentinal tubules, should be a good solvent,
biocompatible, should not produce harmful side effects, and should not interfere with
obturative materials.
Grape Seed Extracts 251
Soligo et al. suggested GSEs as a good auxiliary irrigant solution in endodontic treatment. The antibacterial activity against E. fecalis is seemingly dose dependent of GSEs
[54]. They found good bactericidal activity on E. fecalis using 50% GSE solution, whereas
Ghonmode et al. used much lesser concentration and found no antibacterial effect. Cecchin
et al. also suggested using GSE as a good alternative auxiliary irrigating solution in the
endodontic treatment [55]. They found an improvement in the mechanical properties of
the dentinal walls after using GSE solution. One of the important disadvantages of sodium
hypochlorite (NaOCl) is weakening the dentin surfaces by oxidizing effect during preparation. Thus, the vertical fractures are the leading failures in post-endodontic treatments.
GSE, in turn, strengthens the dentin walls. Though it improves the dentin qualities in the
biomimetic approach, when compared to NaOCl as an endodontic irrigant, no significant reduction in the flexural strength, ultimate tensile strength, and fracture resistance
was found in the GSE group. Although additional improvement was not seen when compared to the control group, GSE could be used to reinforce the dentinal structure, especially in cases where potentially less thickness of the root dentin is found and the cases
allergic to NaOCl.
GSE does not fulfill all the criteria to be a clinically effective endodontic irrigant. The
ability to penetrate the deep dentinal tubules needs to be studied, the bactericidal activity
against different species of the root canal system needs to be evaluated, and optimal dissolving potential should be improved. Concerning the side effects of GSE as an endodontic
irrigant, tooth staining may be a potential side effect that may need to be investigated.
15.5.2
Post Endodontic Restorations
One important disadvantage of GSE as an irrigant is its inability to dissolve the smear
layer and dentin shaves that is mechanically produced during instrumentation. As the
proanthocyanidin produces complexes with the dentin collagen matrix, rather than dissolving, it produces strong complexes, which is good for further obturation. Cecchin
et al. found that pretreatment with GSE in the root canal improves the long-term bond
strength of fiber posts [56]. As we saw, the use of NaOCl produces oxidation, and superoxide radical damages the collagen and weakens the tooth structure. The remaining redox
potential may also interfere with the bonding of obturative materials. Thus, the use of
GSE restores the redox potential, and improves the quality of dentin and bonding of resin-based obturative materials. One study proposes the sequence of NaOCl, followed by
EDTA and GSE as a final irrigant that would help in reducing the side effects of sodium
hypochloride [57].
15.6 GSEs in Periodontics
Another important effect of biofilm in the oral cavity is the manifestation of periodontal
diseases. The predominance of secondary colonizers leads to the development of gingivitis,
periodontitis, and other inflammatory diseases of periodontium as a response to the microbial stimulus. The potential natural agent, GSE, has been studied widely for its protective
effects from the inflammation, preventing fibroblast damage, for its antioxidant effects, as
an antiplaque agent, and as an antibacterial drug.
252 Natural Oral Care in Dental Therapy
15.6.1
Anti-Inflammatory Action in Periodontitis
Pro-inflammatory cytokines are synthesized as a response to periodontal pathogenic organisms. These cytokines induce and maintain the inflammation in periodontitis. Simultaneously,
anti-inflammatory cytokines are produced and try to control the process as a part of healing.
When there is imbalance between the two responses, this leads to periodontal breakdown.
Altered immune response and/or overproduction of cytokines may lead to such conditions
that can be improved with therapeutic compounds, which alter the host response. GSE has
been proposed as a promising immune-modulator due to the PAs [58].
Animal studies were conducted to evaluate the effects of GSE on periodontal inflammation. Govindaraj et al. first demonstrated the antioxidant effects of PAs in the experimentally
induced periodontitis by E. coli endotoxins [59]. Ozden et al. showed the anti-inflammatory
effects on rats by a ligature-induced periodontitis model [60]. They used the dosage of 200
mg/kg body weight GSE without any side effects and estimated the interleukin-10 (IL-10)
levels at various time periods. IL-10 is an anti-inflammatory cytokine, which mediates the
control of periodontal disease progression and modulates the inflammatory response. It
was found that administration of GSE prior to inflammation produced best results with
increased production of IL-10 and protective effects compared with the remaining groups.
PA has been shown to inhibit the tumor necrosis factor-alpha and interleukin-1 beta,
decreases Th1 and Th17A levels, and increases Th2-released cytokines at the inflammation site. It demonstrates the anti-inflammatory action of GSE via regulating the pro- and
anti-inflammatory cytokines.
Another proposed mechanism is through the matrix metalloproteinase (MMP)-8 and
hypoxia inducible factor (HIF)-1alpha [61]. PA administration of 200 mg/kg/day reduced
the ligature-induced periodontitis in rats with diabetes mellitus (induced). HIF-1 is found
more in diabetes mellitus, and PAs significantly reduced them. The decrease in HIF could
be attributed to the improvement in the hypoxic state by administration of GSE. Along with
this, PAs decrease the alveolar bone loss via osteoblast induction. GSE supplementation
significantly improves the periodontitis condition in diabetes by decreasing inflammation,
MMP-8 expression, increasing the osteoblast count and bone formation.
Effects of GSE on the various MMPs have been studied [58]. PAs significantly reduce
the MMP-1, -7, -8, -9, and -13 productions by A. actinomycetemcomitans-stimulated macrophages. Reduction of MMP production is found to be at the concentrations of 12, 59,
and 100 µg/ml. Along with down regulating the MMP, GSE partially reduces the activity of
MMP also. This dual effect of GSE on the MMP proposes it as a host-modulating natural
agent and its application in the periodontal diseases.
15.6.2
Anti-Oxidative Action in Periodontitis
Accumulation of pathogens and persistent release of their byproducts produce destruction of gingivae and periodontium either directly through oxidative damage or indirectly
via inflammatory mediators. Reactive species are produced either by certain bacteria as a
byproduct of their metabolism or by host as a part of immune response. These include reactive oxygen species (ROS) and reactive nitrogen species (RNS). This reactive species cause
oxidative damage via DNA and protein damage, lipid peroxidation, and by initiating inflammation, eventually leads cell death and tissue destruction. PAs are known potent antioxidants.
Grape Seed Extracts 253
Effects of PAs on the three periodontal pathogens were studied in vitro. Pretreatment of
macrophages with 4 µg/ml of PAs reduced the ROS production when stimulated with lipid
polysaccharides (LPS) that are produced by three bacteria. Intracellular ROS production
was inhibited by 43%, 33%, and 48%, respectively, for LPS of A. actinomycetemcomitans, F.
nucleatum, and S. typhosa. PAs showed a strong inhibitory effect on RNS production with
80%, 78%, and 62%, respectively [28].
Cytoprotective effect of GSE is related to its antioxidant potential. Pretreatment of human
gingival fibroblasts with GSE for 1 min produced cytoprotective effects in unfavorable conditions [62]. Other than fibroblasts, human alveolar cells are also protected from cytotoxic
effects. Katsuda et al. reported that the cytoprotective effects of GSE on gingival fibroblasts
are likely to be independent of its antioxidant effects [63].
15.6.3
Antibacterial Action Against Periodontal Pathogens
Antibacterial activity of GSE against periodontal pathogens is found against Aggregatibacter
actinomycetemcomitans, Porphyromonas gingivalis, Fusobacterium nucleatum, Lactobacillus
rhamnosus, Actinomyces viscosus, and Streptococcus sorbinus. The MIC and MBC values
of GSE against periodontal pathogens and anaerobes are relatively high compared to the
MIC and MBC values against cariogenic bacteria, i.e., S. mutans. Different authors found
different values of MIC and MBC. The inhibitory effects of GSE against A. actinomycetemcomitans are quite high with MIC = 3.84 mg/L and MBC = 7.68 mg/L [64]. The MIC value
of F. nucleatum and A. viscosus is 2 mg/mL, and the MBC values are double that of MIC.
The MIC and MBC values for P. gingivalis and L. rhamnosus are found to be higher and
just double that of F. nucleatum and A. viscosus. Furiga et al. found high values of MBC for
P. gingivalis and F. nucleatum, i.e., 8 mg/mL. Despite a high dose, GSEs are well tolerated
without side effects that could be an added value to its clinical applications [37].
All the above studies are of mainly in vitro or animal studies with hypothetic proposals
of GSE as a drug. The first randomized clinical control study on humans was conducted
by Rayyan et al. [65]. They used subgingival application of 2% mucoahesive GSE gel in the
deep periodontal pockets. In the clinical trial, GSE improved the condition of periodontitis
significantly only in periodontal index and gingival index. The periodontal depth of the
periodontal pockets did not improve. For the clinical applications, further trials and studies
are needed.
15.6.4
Antimicrobial Activity in Peri-Implantitis
Maxillofacial defects are rehabilitated with various esthetic prostheses. The seal around
the maxillofacial implants is a crucial factor as it is dynamic, and there is a lack of physical
barrier between the soft tissues and the skin. A lack of hygiene maintenance and compromised seal around the implants leads to altered skin microflora. Staphylococcus aureus
is the most commonly isolated microorganism from the infected implant-abutment site
[66]. GSE is effective against S. aureus. Two strains of S. aureus are found to be susceptible to GSE solutions, ATCC 6538 and a clinical strain. The MIC and MBC value
of both strains are 0.625 mg/mL and 1.250 mg/mL, respectively. Also, GSE exhibits a
dose-dependent inhibitory effect on S. aureus when combined with propylene glycol and
polyethylene glycol [67].
254 Natural Oral Care in Dental Therapy
15.7 GSEs in Oral Cancer
We saw the cytoprotective effects of GSE and its application in the protective side until
now. In the biochemical properties, it was found that proanthocyanidins exert dosedependent selective cytotoxic effects. These were well studied as anti-cancer activity
in the colorectal cancer, anti-proliferative and apoptotic effects on the HCT-8 colon
cancer cell lines, and in vitro human cancer cells [68]. The presence of gallic acids
plays an important role in this. The degree of polymerization and galloylation affect
the cyototoxic effects. On oral carcinoma, GSE shows an anti-proliferative activity
through inhibition of cell growth. The Oral squamous cell carcinoma cells (KB cell
line) are studied for the effects of GSE [69]. GSE, at the concentrations of 250 µg/mL
and incubation at 24 h, exhibits a potent cytotoxic effect on KB cells. It is important
to notice that any anti-cancer drug should not harm the normal cell line. The effects
of GSE on the KB cell line along with the normal cell lines such as human umblical
vein endothelial cells (HUVEC) were studied. The results are promising, with selective
dose- and time-dependent cytotoxicity on the KB cell line without affecting HUVEC
cells. The possible mechanism for this is the induction of apoptosis by GSE, subsequent
DNA fragmentation, and chromatin condensation. The DNA fragmentation analysis
revealed that GSE cytotoxicity on KB cell lines produced DNA fragmentation at the late
stage of apoptosis. In vitro potential needs to be evaluated in further trials.
Cell lines of human gingival cancer Ca9-22 and HGF-1 are also studied for the
dose-dependent effects of GSE [70]. A dose of 150 µg/mL of GSE with 24 h incubation
reduced the Ca9-22 cells to half. The viability of HGF-1 cells is maintained at both low
and high concentrations up to 400 µg/mL. The anti-proliferative effects on oral cancer
CAL 27 cell lines are shown at 30–80 µg/mL. Thus, different cell types require different
concentrations of GSE to inhibit proliferation. Also, GSE has been reported to induce
mRNA over expression of apoptosis-associated signaling. The other activities seen at
the high concentration of GSE (around 400 µg/mL) are ROS production and induction
of apoptosis through high oxidative stress, mitochondrial depolarization, and caspase
activation in Ca9-22 cells.
15.8 Conclusion
Grape seed extract (GSEs) is an emerging natural medicine in various therapeutic procedures in dentistry. It serves as a good alternative in the prevention and treatment of
caries, and in periodontal diseases. The major role provided in the biomodification of
dentine by GSE makes it a biomimetic agent. A paradigm shift is noticed in the use of
natural cross-linkers from a synthetic one, after the development of GSE in the conservative dentistry. Although it is used as a potential antioxidant, anti-inflammatory, and
anti-carcinogenic agent in medicine, for application in dental therapy, further studies are
needed. Very few clinical studies, scarcity of human studies and clinical trials are clear
evidence that there is a need for a huge research and subsequent development of GSE as
a drug in the treatment of oral cancers, in the premalignant lesions, in the endodontic
treatment, and in the periodontal therapies.
Grape Seed Extracts 255
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258 Natural Oral Care in Dental Therapy
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Cytoprotective effects of grape seed extract on human gingival fibroblasts in relation to its
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16
Ocimum Sanctum L: Promising Agent
for Oral Health Care Management
Trinette Fernandes1, Anisha D’souza2 and Sujata P. Sawarkar1*
1
Department of Pharmaceutics, SVKM’s Dr. Bhanuben Nanavati College of Pharmacy,
University of Mumbai, Maharashtra, India
2
Formulation Development Laboratory, Piramal Enterprises Limited, Light Hall, Chandivali, Powai,
Mumbai, India
Abstract
Dental caries was considered as the most prevalent condition affecting 2.4 billion people worldwide (2010), and the 10th most prevalent condition affecting 621 million children on a global scale.
Bacteria like Streptococcus mutans, Streptococcus sobrinus, Enterococcus faecalis, and Lactobacilli are
responsible for formation of dental plaque. Natural products such as Ocimum sanctum L. extract
have been used for treatment of various ailments since ancient times and have been mentioned in
ancient texts such as Atharvaveda. The mention of Ocimum sanctum L. in literature dates back to
1200–1000 BC wherein it is called as the “elixir of life”. Ocimum sanctum L was reported to be used
for oral care and halitosis as they have anticariogenic properties. The anti-inflammatory agents in
Ocimum sanctum (Tulsi) also contribute to the reduction of inflammation of gums, which is characteristic of periodontal diseases such as periodontitis and gingivitis. In vitro tests on oral pathogenic
bacteria shows that Ocimum sanctum L extract in the form of toothpastes, mouthwash, and gels
have antibacterial activity against Streptococcus mutans and Enterococcus faecalis. Recently the formulations of Ocimum sanctum L loaded in novel drug delivery system have been developed for the
treatment of various conditions such as acne, arthritis, etc. Mouthwashes, gels, and toothpastes containing Ocimum sanctum L-loaded particulate systems can potentially be researched in the future.
Keywords: Ocimum sanctum L, tulsi, oral health, antibacterial, antibiofilm, antifungal, periodontal
diseases
16.1 Introduction
Oral Hygiene and dental public health have always been neglected issues although it is a
well-known fact that oral cavity is the gateway to external environment and the first entry
point of plethora of microorganisms to the human body. It is required to be well understood that dental health, if neglected, can lead to fatal ailments like cardiovascular diseases,
*Corresponding author: sujata.sawarkar@bncp.ac.in; sujatasawarkar19@gmail.com
Durgesh Nandini Chauhan, Prabhu Raj Singh, Kamal Shah, and Nagendra Singh Chauhan (eds.)
Natural Oral Care in Dental Therapy, (259–270) © 2020 Scrivener Publishing LLC
259
260 Natural Oral Care in Dental Therapy
pneumonia, stroke, etc. Bacteria are major causative organisms for dental diseases. Dental
caries and periodontal diseases are the most common chronic diseases.
Dental caries, also known as cavities, often lead to dental plaque and bio-film formed by
Streptococci and Lactobacilli species [1]. Formation of bio-film around the gingiva causes pathogenic conditions like gingivitis, inflammation of gingiva, softening of gums, and bad breath.
Further erosion of enamel spreads to tooth pulp further leading to abscess and periodontitis.
Several noninvasive or invasive surgical treatment modalities are adopted initially
depending on the severity of the disease followed by local administration of antimicrobials
and antibiotics like doxycycline, minocycline, chlorhexidine, cetylpyridinium chloride, or
triclosan either as powders or gels, implants, or in the form of tablets and capsules for oral
administration. Chemically synthesized drugs have their own share of drawbacks like poor
bioavailability and therefore low therapeutic efficacy, systemic side effects, staining of teeth,
and calculus formation as commonly associated with chlorhexidine and cetylpyridinium
chloride. Considering the present scenario and the pros and cons of modern allopathic
drugs of synthetic origin, researchers should revisit and employ traditional medicine for
mitigation of dental disease [2].
16.2 History of Ocimum sanctum
Plants are the inevitable segment and quintessential source of drug or therapy in different
traditional medicinal systems be it Ayurveda, Unani, or Traditional Chinese Medicine. Like
Traditional Chinese Medicine, Ayurveda and Unani System also use different parts of plants,
which are formulated as pills, powders, decoctions, extracts, juices, oils, and infusions. Many
synthetic analogs have been prepared from prototype compounds isolated from plants.
Ayurveda includes the uses of about 2,000 plant species, Unani literature mentions about
1,000 plant species, and Chinese Herbal Medicine mentions about 11,000 plant species [3].
Among the drugs of ancient times, Ocimum sanctum and other Ocimum species have been
extensively researched in medical science. Ocimum sanctum L. or Ocimum tenuiflorum L,
known as the Holy Basil in English or Tulsi in the various Indian languages is a well-known
medicinal plant in the various traditional and folk systems of medicine in Southeast Asia.
Ocimum sanctum L. is indigenous to tropical areas and is perennial in nature. The shrub grows
up to 18 inches in height and blooms flowers in June to August (or about 150 days from planting the seed). The leaves are 5-cm long, green to purple in color, and ovate in shape. The border
of the leaves is serrated and form reddish brown fruits. The Ocimum genus consists of at least
65 species, from which Ocimum sanctum, Ocimum bascilicum, Ocimum gratissimum, Ocimum
kilimandschricum, Ocimum americanu, Ocimum camphora, and Ocimum micranthum are
known for their therapeutic activity. The current chapter will discuss briefly about Ocimum
sanctum Land and its chemical constituents. Various applications of Ocimum sanctum in dentistry and various marketed products will also be briefed upon in the further sections.
16.3 Chemical Constituents of Ocimum sanctum
The plants coming under the genus Ocimum belong to the family Lamiaceae. There are about
150 aromatic annual and perennial herbs and shrubs that grow naturally or are cultivated in
Ocimum Sanctum L. 261
tropical and subtropical regions of the world. Ocimum sanctum L. or Ocimum tenuiflorum,
popularly known as Holy basil, is used as a whole plant or in individual parts of the plant
(leaves, flowers, root, seeds, and stem) in various forms such as decoction/tea, powdered
extract, or fresh leaves. The shrub grows up to 18 inches in height and blooms flowers
in June to August (or about 150 days from planting the seed). The leaves are 5-cm long,
green to purple in color and ovate in shape. The borders of the leaves are serrated and form
reddish brown fruits. The other species of the Ocimum genus comprised of Ocimum bascilicum, Ocimum gratissimum, Ocimum kilimandschricum, Ocimum americanu, Ocimum
camphora, and Ocimum micranthum, are known for their therapeutic activity [4, 5].
Based on the research studies conducted so far, Ocimum extracts have shown to have
antibacterial, antifungal, anti-inflammatory, analgesic, antipyretic, antidiabetic, hepatoprotective, hypolipidemic, immunomodulatory, and cardioprotective activities [4–8].
Tulsi leaves primarily contain volatile oil, about 0.7%. The major constituents of volatile
oil are 71% eugenol and 20% methyl eugenol. Apart from these, the other constituents present are carvacrol, linalool, limmatrol, sesquiterpine hydrocarbon, caryophyllene, cirsilineol, circimaritin, isothymusin, and apigenin. In addition, the leaves also contain orientin,
vicenin, ursolic acid, apigenin, luteolin, apigenin-7-O-glucuronide, luteolin-7-O glucuronide, molludistin, and sesquiterpenes and monoterpenes like bornyl acetate, α-elemene,
neral, myrtenal, α- and β-pinenes, camphene, campesterol, stigmasterol, and β-sitosterol.
All these constituents exhibit a wide plethora of therapeutic effects [4, 9, 10]. The quantities of each of these constituents are highly variable as primarily it depends on harvesting,
treatment, and storage conditions, geographic, and biodiversity. The essential oils present in
Ocimum extracts have promising antibacterial activity.
The major constituents that have been isolated from the different Ocimum oils include
1,8-cineol, linalool, pinene, eugenol, camphor, methyl chavicol, ocimene, terpinene, limonene, etc. Researchers have extensively studied the relationship between the composition
of oil and biological activity. In India, there are two main subspecies of Ocimum sanctum
obtained, viz. Ocimum sanctum L. green (Tulsi) and Ocimum sanctum purple (Krishna
Tulsi). The essential oils obtained from both these subspecies differ in their composition.
The green type of subspecies contains eugenol, limonene, and E-caryophyllene, whereas the
purple contains eugenol and E-caryophyllene.
These essential oil components show antibacterial activities by varied mechanistic
pathways.
Eugenol shows a mechanism of action by membrane disruption by inhibiting ATPase
activity, possible efflux pump blocker, and reduction of several virulence factors at subinhibitory concentrations. Thymol causes membrane disruption with potential intracellular
targets, along with disruption of citrate metabolic pathway. Carvacrol exhibits membrane
disruption, inhibition of ATPase activity, membrane destabilization, leakage of cell ions,
fluidization of membrane lipids, and reduction of proton motive force [11]. The table 16.1
below mentions the chemical constituents and their pharmacological activity:
Literature reports have shown that several phyto constituents in essential oils obtained
from Ocimum extracts have shown promising therapeutic activity. It is quintessential to
extract, isolate, and identify them. The following section mentions the details of various
extraction procedures reported.
Extraction of Ocimum sanctum L can be carried out by Maceration, Soxhlet, Supercritical
fluid extraction, Ultrasonic extraction, and Microwave-assisted extraction [12–14].
262 Natural Oral Care in Dental Therapy
Table 16.1 Pharmacological activity of phyto constituents of Ocimum.
Sr no
Chemical constituents
Pharmacological activity
1.)
Eugenol
Anti-inflammatory, antitumor, antibacterial,
antiviral
2.)
Ursonic acid
Anti-inflammatory
3.)
Rosmarinic acid
Antioxidant
4.)
Limonene
Antioxidant
5.)
E. Caryophyllene
Anti-inflammatory and antioxidant
6.)
Isothymustin
Anti-inflammatory
Various analytical methods are used for isolation and identification of chemical constituents in different types of Ocimum sanctum L. LC-MS is the most extensively used method
for isolation of flavonoids [15, 16]. In addition, GC-MS is also used for separation of constituents [17]. Eugenol is the major constituent detected by this method. HPTLC and NMR
are also used for identification of the active constituents in Ocimum sanctum L. For characterization of total flavonoid and flavone content, spectrophotometric assay can be carried
out. Total phenolic content can be quantified by modified Folin–Ciocalteu’s method.
16.4 Therapeutic Significance of Ocimum in Dental Health
and Preventive Care Management
Ocimum sanctum has been used as an active agent and is an age-old remedy for various ailments. In the field of dentistry, it has been mainly researched for its use as an antibacterial
and anti-inflammatory agent for plagues, dental caries, and periodontitis. Ocimum sanctum
has multifaceted activities mainly attributed to constituents such as Eugenol, Methyl eugenol, Ursolic acid, and rosmarinic acid. As mentioned in an earlier section, the therapeutic
constituents show antibacterial activities by varied mechanistic pathways, viz. membrane
disruption by inhibiting ATPase activity, membrane disruption, efflux pump blockage,
reduction of several virulence factors. Ocimum sanctum extract has been tested for antibacterial activity against periodontal pathogens, such as Streptococcus mutans, Aggregatibacter
actinomycetemcomitans, and Porphyromonas gingivalis. The extract showed superior activity when compared to other herbal agents and also was equivalent/superior to established
gold standards i.e. Chlorhexidine, Triclosan, and CetylPyridinium Chloride. The superior
activity was attributed to the presence of Eugenol in Ocimum extract [12, 18–27].
The activity of essential oils derived from Ocimum has been examined extensively for
their capacity to control oral cariogenic bacteria and biofilm-forming microorganisms like
Streptococci and Lactobacilli species [28–30, 49].
Ocimum can be used in various forms for its anticariogenic activity. The most common
traditional method has been chewing whole leaves. Lolayekar, N.V. and Kadkhodayan, S.S
conducted a study involving the evaluation of the eradication of Streptococcus mutans from
the oral cavity. The study showed a statistically significant (P < 0.05) difference in the colony
Ocimum Sanctum L. 263
count of Streptococcus mutans in saliva in the clinical volunteers aged between 9 and 12
years [31].
In another study, the researchers evaluated the thickness of tongue coating and salivary
pH before and after chewing Ocimum sanctum (Tulsi) leaves. The study collected the saliva
sample and checked the tongue coating on the first, second, and seventh day. The study
showed an increase in saliva pH level after 30 min of chewing Tulsi leaves. The observations
were correlated to decrease in acidic conditions required for induction of cariogenesis and
tongue coating and halitosis [32].
The dental activity of Ocimum sanctum has been profoundly envisaged when administered in the form of mouthwash, gargles, and mouth irrigants. In recent times, several
commercial oral health care products available in domestic and international markets
contain essential oils derived from Ocimum species. Pereira SL et al. and Pimenta MS
prepared a mouthrinse from the extract of Ocimum gratissimum and compared it with
Chlorhexidine Digluconate solution in a clinical study conducted on human volunteers.
The investigators evaluated the formulations with respect to biofilm and gingivitis control.
The study showed a reduction in plaque and inflammation in the volunteers. In addition
to this, it also showed a reduction in recurrence in the formation of new biofilm for up to 3
days after removal of the plaque [33, 34]. Gupta et al. conducted a randomized controlled
clinical trial of Ocimum sanctum and Chlorhexidine mouthwash on dental plaque and gingival inflammation in 36 patients. The study results concluded that Ocimum mouthwash
was equally effective as Chlorhexidine in mitigating plague and gingivitis. The interpretations were made on the basis of measurement of plaque index and reduction in gingival
bleeding and inflammation. Ocimum mouth rinse was well accepted by participants as it
did not give any burning sensation as commonly associated with the use of Chlorhexidine
mouthwash [35].
The presence of residual bacteria after root canal treatment often causes periradicular
lesion often leading to failure of therapy [36]. In order to eradicate these residual bacteria,
dental irrigants are employed. Dental irrigants or mouth irrigants involve the use of fluids sprayed at high pressure in the mouth cavity to provide a scaling-like action and help
with blood flow and promote healing of the alveolar tissue. Tulsi extract, as the main active
ingredient or in combination with other herbal active constituents, has been used for disinfecting the dental cavity and subgingival region. Ocimum sanctum extract has also shown
evidence for intracanal medication as dental irrigant.
Gupta-Wadhwa J et al. conducted a clinical trial on 108 volunteers to check the reduction
in Enterococcus faecalis posttreatment with Cinnamomum zeylanicum, Syzygium aromaticum, and Ocimum sanctum extract. The treatment showed significant reduction in bacterial
levels in the dental cavity [37].
However, the effect of the extract failed to provide superior disinfection compared to
strong chemical agents such as Sodium Hypochlorite. In another study, it was concluded
that the increase in disinfectant activity of Sodium Hypochlorite along with herbal extracts
can help to control the bacterial colonies [38, 39].
In addition to gingivitis and root canal disinfection, Tulsi was also researched for activity in the treatment of oral mucosal fibrosis. The treatment showed significant increase
in mouth opening and reduction in burning in the volunteers. Reduction in symptoms
confirmed the potential of Tulsi extract as adjuvant therapy in the management of oral
submucosal fibrosis [40].
264 Natural Oral Care in Dental Therapy
Ocimum sanctum, being an antibacterial, is also reported for its use in periodontitis.
Ocimum sanctum gel (2%) was studied in Wistar rat model after inducing periodontitis
by a ligature model. Gel was made of Carbopol (2 g) and Hydroxypropyl methyl cellulose
HPMC (2 g) with propylene glycol (5 ml) with a preservative. The gel inhibited 33.66% of
edema with maximum activity observed at 24 h. The gingival index and probing pocket
depth were significantly improved with no toxic effects [41].
16.5 Novel Drug Delivery Formulations and Its Application
in Dentistry
Application of novel formulation strategy and nanotechnology for herbal drugs and their
phyto constituents can help in promoting their therapeutic benefits. The various drug delivery systems studied for the delivery of Ocimum or explored for its activities is mentioned in
the following sections.
16.5.1
Nanofibers
Resorbable nanofibers containing Ocimum sanctum (1–20% w/w)-loaded polyvinyl vinyl
acetate have also been studied for periodontitis. The nonwoven nanofibers were prepared
by electrospinning to give high tunable porous and large surface area. Viscosity of solution diameter of needle (12 mm, 22 mm, 0.91 mm, 0.4 mm), solution flow rate (500 µl/h,
0.8 ml/h, 1 ml/h, 1.5 ml/h), and tip to collector distance (12 cm, 22 cm, 16–18.5 cm), the
parameters of the nanofibers, can be controlled to obtain nanofibers of required parameters. Beadless and uniform fibers were formed with 10% of Ocimum concentration when
the tip-to-collector distance was 12 cm, the diameter of the needle was 12 mm, with a solution flow rate of 500 µl/h, and with an applied voltage of 13 kV [42].
16.5.2
β-Cyclodextrin Complexes
To improve the stability of essential oil from Ocimum sanctum, against environmental
conditions like oxygen and temperature, supramolecular complexation with β-cyclodextrin with essential oil was studied. The supramolecular structure protected the oil
against degradation especially linalool and methyl chavical (estragole) as determined by
GC-MS [43].
The supramolecular structure exhibited an anti-inflammatory effect in acute and chronic
inflammation mice models by decreasing vascular permeability, leukocyte recruitment to peritoneal cavity, and granuloma formation. The activity can be explored for anti-inflammation
in periodontitis [44].
16.5.3
Biocompatible Ocimum sanctum-Coated Silver Nanoparticles
Plant extracts have been popularly used for green synthesis of silver nanoparticles. They
facilitate synthesis of the inorganic nanoparticles making them more biocompatible and
eco-friendlier, besides being cost-effective. Plant extracts reduce the Ag+ ions to Ag(0) in
the form of nanoparticles. Silver nitrate is reduced when kept at 80°C temperature within
Ocimum Sanctum L. 265
45 min. Similarly the leaves of Ocimum sanctum assisted in the formation of silver nanoparticles ranging from size 5 nm to 40 nm depending upon the concentration of silver nitrate
and leaf extracts. Eugenol, the phenolic compound is responsible for the capping activity
and reduction process due to their redox property of neutralizing and absorption of free
radicals. The capping agent prevents the agglomeration of nanoparticles due to the high
affinity of the carbonyl group in the amino acid residues in Ocimum with silver. Besides,
other antioxidants like Vitamin-C also play a major role. Air-dried leaves of Ocimum sanctum, usually done by keeping at 60°C for 48 h in a hot air oven followed by grinding and
extraction with water, were used for reduction. The rate of reduction is faster with the
extract of Ocimum sanctum compared to other plant leaf- as well as microbe (bacteria and
fungi)-based synthesis. Formation of silver nanoparticles is confirmed by strong plasmon
resonance at 440 nm. The silver nanoparticles give a characteristic yellowish-brown color
[20, 45]. The silver nanoparticles thus synthesized have usually a cubic lattice structure of
nano scales and a coat of biocompatible plant proteins [46].
However, the silver nanoparticles with desired characteristics can be obtained by changing the plant culture conditions. For instance, spherical-shaped crystalline silver nanoparticles with a size of 13.82 nm could be obtained from the extract of Ocimum basilicum, which
was grown in vitro. The antibacterial effect against Gram-negative and -positive bacteria
was retained [47]. Likewise, the presence of Cetyltrimethylammonium bromide revealed
spherical nanoparticles ranging from size 18 to 35 nm but with triangular truncated nanoplates, which looked like a silver locket capped with O. sanctum biomolecules. The polydispersity of the nanoparticles was very high.
A research group successfully evaluated both the green and purple varieties of Tulsi, i.e.,
Ocimum tenuiflorum L. green (known as Sri Tulsi in India) and Ocimum tenuiflorum L. purple (known as Krishna Tulsi in India) for bio reduction of silver nitrate to <100 nm-sized
silver nanoparticles and found no significant difference. The presence of C–H vibration contributed by aromatic ring and stretch C–O vibrations from carbonyl group and flavonoids
confirmed the same [50]. Extract of Ocimum basilicum leaves and Ocimum gratissimum
Linn also have been successfully used in the generation of silver nanoparticles [48, 49].
Ocimum tenuiflorum leaf also yielded silver nanoparticles with good antioxidant potential and good catalytic reduction [51].
The synthesized nanoparticles were stable up to 4 months at room temperature and
exhibited a lower minimum inhibition concentration compared to the nanoparticles biosynthesized using Garcinia mangostana against Staphylococcus aureus and E. coli [52].
Another research indicated that the antimicrobial activity of such silver nanoparticles
was highly enhanced against Escherichia coli and Staphylococcus aureus when Ocimum was
used for reduction. Fresh leaves of Tulsi were used for extraction. However, conversion to
silver nanoparticles took almost 2 h [53].
16.6 Conclusion
The uses of Ocimum sanctum in dentistry has been documented in various ancient literatures. The mention of Ocimum sanctum L. in literature dates back to 1200–1000 BC wherein
it was called as the “elixir of life”. The amount of active chemical constituents isolated
from the crude extract depends on the type of extraction process implemented. Chemical
266 Natural Oral Care in Dental Therapy
constituents such as Eugenol, Rosmarinic acid, Isothymusin, and Ursolic acid were proven
to have antibacterial and anti-inflammatory activities. Tulsi has been reported to be used
for oral care and halitosis as they have anticariogenic properties. The anti-inflammatory
agents in Tulsi also contribute to the reduction in inflammation of gums, which is characteristic of periodontal diseases such as periodontitis and gingivitis. Ocimum sanctum L
is also used as a wound healing agent. This property is proven beneficial in alveolar bone
regeneration and postsurgical periodontium healing. The potential of Ocimum sanctum
extract for use in various formulations such as gels and mouthwashes has been explored.
The use of nanoparticles for the delivery of Ocimum sanctum helps in localized delivery of
the extract. Metal nanoparticles such as silver, iron oxide, gold, and platinum are prepared
using Ocimum sanctum extract. These nanoparticles are potent antibacterial and can be
potentially incorporated in the formulation of mouthwash, toothpastes, gels, etc.
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268 Natural Oral Care in Dental Therapy
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17
Coconut Palm (Cocos nucifera L.): A Natural Gift
to Humans for Dental Ministration
Navneet Kishore and Akhilesh Kumar Verma*
Department of Chemistry, University of Delhi, North Campus, New Delhi
Abstract
Coconut palm is scientifically known as Cocos nucifera L. (family: Arecaceae), which originated from
southeast Asia and also across the Indian and Pacific islands. This plant has been used for a long
time to treat a diverse range of human ailments in Ayurveda. According to Ayurveda, this plant is
designated as a tree that provides all necessities to live. Approximately all parts of this plant are useful
either medically or in other approach. Scientific reports disclose that it is one of the most valuable
trees for dental care therapy. Coconut oil is one of the most important constituents to overcome
various human ailments in traditional therapies. This oil has significant antibacterial, antifungal, and
antiviral properties, which help to eradicate harmful microbes from oral cavity during oil pulling.
Coconut water is an important component to preserve periodontal ligament cell viability and transport media to tear off a tooth. It is also defined as a nutritional power booster drink and has achieved
international acclaim as natural sport drink. It is a clear liquid containing various nutrients with
electrolytic property. It improves the skin tone and reduce the swelling through the advancement
in immune function. It is also a better root canal irrigant due to its antimicrobial potential. Hence,
this plant is accredited with several potential remedial actions in, for example, oral cavity disorders.
The present chapter focused on up-to-date entries regarding traditional, ethnopharmacological, and
bioactive phytochemicals and on significant use of coconut plant in oral cavity therapies.
Keywords: Cocos nucifera L., medicinal value, coconut oil, coconut water, dental care
17.1 Introduction
Oral cavity disorders are associated with the bacterial infections which originate serious health delinquencies in human beings around the world [1, 2]. The most prominent bacterial species accountable for periodontal diseases include Streptococcus mutans,
Porphyromonas gingivalis, Prevotella intermedia, and other related bacterial species. All
these species are responsible for various dental disorders that eventually lead to tooth
decay, because they were isolated and identified from dental eruptions of human oral
cavities [3, 4]. Suppressed concentrations of the aforesaid bacterial species in oral cavity
could be the great achievement to overcome periodontal diseases. The inhibition of oral
*Corresponding author: akhilesh682000@gmail.com
Durgesh Nandini Chauhan, Prabhu Raj Singh, Kamal Shah, and Nagendra Singh Chauhan (eds.)
Natural Oral Care in Dental Therapy, (271–284) © 2020 Scrivener Publishing LLC
271
272 Natural Oral Care in Dental Therapy
cavity ailments can be done by the eradication of these microbial species. There is approximate 90% of dental detonations encountered in teenagers and adult populaces which
is preposterous. The plant-based drug development has constantly been an exceptional
source for the invention of novel scaffolds [5, 6]. Hence, the medicinal plants provided a
number of secondary metabolites for periodontal care to date, and many more are identified from the day-by-day research going on the respective field. Consequently, today, the
universal requirements for the assessment of plant-derived compounds could be used in
the treatment of dental diseases and the creation of alternative therapies from medicinal
plants.
Coconut palm (Cocos nucifera L.) belongs to the family Arecaceae, which originated from
southeast Asia and also across the Indian and Pacific islands [7]. This plant has been used for
a long time to treat a diverse range of human ailments in Ayurveda. According to Ayurveda,
this plant is designated as a tree that provides all the necessities to live. Approximately all
parts of this plant are useful either medically or in other approach. Its annual production
is 61 million tons, which is encountered in approximately 90 countries worldwide. An estimated 73% of production is attributed to India, Indonesia, and the Philippines [8]. Several
edible products made from coconut tree are orally taken as a tradition of many communities to maintain smooth natural life. Coconut milk is very operative to enhance in the
growth of plant. Coconut water is a very efficient pure drink full of natural sugars and is
99% fat free with a lower level of carbohydrates. The electrolytic nature of coconut water
due to the presence of ionic mineral, its constituent, is comparable with human plasma.
This resemblance made it a global sport drink to cure oral dehydration [9]. Various parts
of this tree, including leaves, fruits, spathe, flowers, flesh, husk fibers, coconut water, coconut oil, trunk, coconut milk, coconut shell, and roots, are very significant to make several
medicinal and household products.
17.2 Traditional Usage and Ethnopharmacological Relevance
Coconut is extensively used in traditional medicine for the treatment of a large assortment
of human and animal ailments, which is also illustrated in Ayurveda. Coconut oil is applied
on the backbone and stiff joints to relieve back pain and arthritis. It is also rubbed on the
body as an ointment to preserve soft and smooth skin [10]. A mixture of coconut oil with
turmeric powder is applied on newly born babies as well as mothers after delivery. Women
desolated by complicated pregnancies are advised to take green coconut juice. Fruit juice
helps in kidney nuisance and roots are applied on stomach pain, whereas a decoction with
the root of Ruellia tuberose is a good remedy for bladder treatment. An extract from stem
is proficient to overcome weakness after childbirth. Skin disorders like scabies, sores, and
ulcers are treated with external application of apical bud in the form of poultice. Some parts
of the plants are also used in the treatment of diarrhea and dysentery [11]. South Indian
village people use husk fibers to brush their teeth. It is also used in folklore therapies to
treat skin-related disorders such as skin burns, toothache, sunburns, sores, and ringworms.
Massage using coconut oil makes skin soft and youthful and eradicates the cracks of heel
and blackening portion of armpits. It eradicates dandruff and improves the scalp and hair. It
is used to relieve stomach complications such as acidity and colitis. It is also quite effective
in treating urinary glitches. It is helpful to treat the inflammation of mucosal membrane
Coconut Palm (Cocos nucifera L.) 273
and measles. An intake of the combination of coconut milk and its flesh with honey by
males and females strengthens their sexual appetite [12].
17.3 Pharmacological Properties of Coconut
Coconut tree has been recognized as a medication for a diverse range of sicknesses in various populaces due to its rich fiber contents, minerals, and vitamins with higher nutritional
value. The presence of diverse mineral constituents in coconut water is used as an efficient
storage medium and for tissue culture [13]. Diseases associated with oral cavity including
gingivitis and tooth decay disturb approximately 60–90% of youngsters as well as a massive community of adults. Prophylactic effects of coconut water have also been observed
from the ethylene glycol induced in mice [14]. Previous literature reports disclose that the
antibacterial potential of coconut oil counters several strains of the genus Streptococcus
including S. mutans. S. mutans is a species that causes tooth decay and extreme gingivitis.
An antibacterial investigation on coconut alcoholic extract displayed good zone of inhibition against many bacterial species such as S. mutans, Prevotella intermedia, S. salivarius,
S. mitis, Lactobacillus acidophilus, and Candida albicans (fungal) in the concentrationdependent method [11]. The pro-inflammatory properties of coconut are non-toxic in
nature, and they are also helpful in the treatment of diabetic patients and prostatic hyperplasia [15]. When used in diet, Cocos nucifera is competent to overcome diabetes mellitus [16].
In a recent investigation, it has been proved that coconut extract exhibits significant antidiabetes property. Results showed that a combination of 250 mg/kg extract with 22.5 mg/
kg of metformin expressively lowered the level of PGL in the duration of 7th, 14th, 21st, and
28th days. It has also been confirmed that, it halts pancreatic diminishing after the treatment
with coconut water [17]. Coconut fruits are helpful in the treatment of disorders in cardiac
metabolism [18]. They are also very helpful in the restoration of islets of Langerhans b
cells due to the presence of amino acids [19]. Other significant pharmacological properties include aphrodisiac, antiseptic, antioxidant, antihelminthic, antitumor, stomachic, and
bactericidal [20]. The rich compositions of polyphenols regulate the metabolism of carbohydrate and lipid as well as insulin management.
Coconut tree also helps to improve the metabolism of adipose tissue and signalling pathways [21]. Cocos fruits are enriched with lauric acid, which is responsible for the antimicrobial actions against some oral cavity contagions. The chemical components glycolipids
and sucrose monolaurate existing in coconut are also liable for anti-dental carries. It is supposed to inhibit dental plaque in the tooth caused by S. mutans via reduced glycolysis and
oxidation of sucrose. In recent reports, ethanolic leaf extract displayed protection against
paralysis effect, inhibition of acetylcholinesterase as well as scavenger of free radicals [22],
anthelmintic action [23], and antioxidant potential against reactive oxygen species [24].
There is a report on coconut water that showed that it significantly helps to protect cardiac
problems [25].
Tender coconut water (TCW) is an efficient drink that has several health reimbursements without any adverse effect on the human body. The zone of inhibition is observed
with values of 14.23 and 3.08 by the sterilized TCW and fresh TCW, respectively. The value
of the zone of inhibition was clearly inferior to chlorhexidine, used as a standard drug [26].
An in vitro analysis of green coconut water was conducted against fungal species Candida
274 Natural Oral Care in Dental Therapy
Anti-atherosclerotic action
Anti-inflammatory action
Anti-leishmanial activity
Anti-cholecystitic action
Anti-malarial activity
Anti-diabetic activity
Anti-neoplastic activity
Cardio protective effect
Anti-oxidant activity
Hepatoprotective activity
Anti-parasitic activity
Hypolipidemic effect
Anti-thrombotic action
Gastrointestinal disorders
Anthelmintic activity
Anti-hypertensive action
Immune stimulatory effect
Antidote Action
Endosperm
Hormonal effect
Disinfectant activity
Antiprotozoal action
Best electrolyte
Protect teeth and
gums. A better
storage medium
for avulsed tooth
Virgin
Coconut
Oil
Coconut
Oil
Fresh
Coconut
Water
Anti-bacterial action
Anticonvulsant action
Figure 17.1 Represents the incredible medicinal value of the coconut tree.
albicans over broth microdilution assay in an agar culture. The antifungal potential of this
water was observed to be comparable to standard drug amphotericin B at a concentration
of 1000 μg/mL and repressed the progress of fungal species by 14.0±03 and 15.0±03 for
positive control [27].
17.4 Role of a Coconut Tree in Dental Ministrations
A systematic analysis of the endocarp of coconut proved that it is an affluent source of flavonoids and phenolic content. With the occurrence of these compounds, endocarp displays
very good antimicrobial, antioxidant, and antihypertensive effects along with the inhibition of bacterial species existing in the oral cavity [28, 29]. The antimicrobial potential of
alcoholic extract from husk fibers against oral pathogens, namely, Fusobacterium nucleatum, Lactobacillus casei, Porphyromonas gingivalis, Prevotella intermedia, and Streptococcus
mutans, has been evaluated [30]. The result displayed significant potential against oral
dentistry pathogens [31]. The antimicrobial susceptibility and cytotoxicity action have also
been evaluated for husk ethanolic extract against three endodontic pathogens species, viz.,
Porphyromonas gingivalis, Prevotella intermedia, and Enterococcus faecalis [32]. The most
efficient practice from the earliest periods to cure teeth is oil pulling. In this practice, coconut oil is used and helps to preserve healthy teeth. Extra virgin coconut oil of about 5–10 mL
is taken in the mouth to rinse the oral cavity for 15–20 minutes [29]. This action removes all
Coconut Palm (Cocos nucifera L.) 275
1. Coconut Leaves
2. Coconut Spathe & Flowers
3. Coconut Young Fruits
4. Coconut Flesh
5. Coconut Endosperm
6. Coconut Shells
7. Coconut Husk Fibres
8. Coconut Trunk
9. Coconut Roots
Figure 17.2 Represents the various parts of coconut (Cocos nucifera L.) tree.
the harmful bacterial species as well as other microorganisms and also reconciles the gums.
A strong electrolyte inside the fruits contains chief essential minerals such as calcium, magnesium, and potassium, which are rich in amount. Coconut water also contains cytokinin
hormone, which normalizes growth and aging; it encourages the use of coconut water in
tissue culture. With the feasibility of periodontal ligament cells in coconut water, it is used
in emergency cases for the transportation of avulsed tooth [33].
17.5 Exemplary Potential of Coconut Water in Dentistry
The consumption of coconut in everyday regime in several traditions not only affords good
taste but also preserves healthy life devoid of various illnesses. The electrolytic liquid inside
the fruits is a good rehydrating drink, a transference mediator for avulsed tooth, blood
exchange, and a culture medium in cell culture laboratories [34]. Earlier lessons suggested
coconut oil to be used in folk therapies for various dental complaints, and it achieved excellent recognition for folk solidification of teeth and exudates, deterrence of tooth falloff, bad
smell from oral cavity, bloody gums, and splintered lips [35]. The usage of plant-based folklore remedies is documented in the Ayurveda; hence, these tactics need scientific authentication of herbal products in oral cavity disorders [36]. Hence, it exhibits excellent relief of
pain and swelling and is used as a root canal irrigant due to its antimicrobial properties. It
is used as storage medium for avulsed tooth.
Moreover, coconut water has been recognized as a new enhanced choice to store avulsed
teeth because of its significant viability and preservation of periodontal ligament cells [9].
276 Natural Oral Care in Dental Therapy
A number of herbal decoctions displayed extensive accomplishment in dentistry after treating different dental disorders. Plant-based natural compounds are a paramount alternative
source to prevent several oral illnesses. However, the prolonged used of these herbal formulations is much safer and convenient compared to synthetic drugs. The assessments of available herbal remedies are still mysterious; an enormous use of these products is expected in
the future. There are several aspects to acquire more data through further investigation with
regards to these herbal products assured for dental disorders [37].
Several reports on coconut water in dentistry published in very recent years are discussed here. The viability of PDL fibroblasts was observed in skimmed milk followed by
salt solution and coconut water [38]. A study conducted on the pH-adjusted coconut
water showed significant viability of periodontal ligament cells, and it can preserve the
viability of avulsed teeth for up to 24 hours [39]. Another lab report also supported the
cell viability of periodontal ligament cells in coconut water [40]. In a recent report, it was
revealed that the new formula developed from the powdered coconut water (ACP-404)
showed significant PDL cell viability. This study was carried out on 60 teeth of a dog
that were successfully replanted after the storage of newly formulated ACP-404 storage
media [41].
In another research group, a setup of an in vitro experiment for 69 human premolars along
with normal periodontium was divided into three groups of 23 each. They were preserved
into three different storage media, viz., coconut milk, Hanks’ balanced salt solution (HBSS),
and probiotic milk. Results showed noteworthy dissimilarity in the maintenance of cell viability between the three storage media used. Hence, this study determined that the coconut milk
is not appropriate due to poor cell viability for interim media for transportation. However,
HBSS and probiotic milk showed good preservation of PDL cell viability [42].
17.6 Other Significance of Coconut
A number of reimbursements have been attributed to coconut tree starting from the top
of the leaves to the bottom of its roots in numerous civilizations of different countries. The
wide range of products is accountable for their medicinal persistence, building material for
houses, food stuff, decoration etc. [43]. The significance of various parts of coconut tree has
been discussed in this segment.
17.6.1
Economic Value of Coconut Leaves
In Maldives, leaves of coconut tree are used as a household material for making roof, and
in the Philippines, they are used for cooking, to wrap rice, and for storing rice. The leaves
of coconut tree are generally durable for 1 year. The leaves are substantial to make brooms
and toys and are burnt to make lime in India; leaf midribs are used to make skewers and
toothpicks. Stems of coconut tree are used to make boats, canoes, drums, furniture and,
houses as timber. These leaves are very long and disbursed to generate inimitable look in
landscape design. Coconut leaves are also a very favorite fodder for elephants. The leaves
are also useful to make trays, hats, paper pulps, umbrellas, ropes, barbecue skewers, and
cover for books.
Coconut Palm (Cocos nucifera L.) 277
17.6.2
Use of Coconut Heart
The coconut heart is generally known as “Palmis,” and it is very demandable for invitees
and resident societies due to its delightful taste. These are mainly taken in salads as well as
other cookeries.
17.6.3
Significance of Spathe and Inflorescence
The covering of coconut inflorescence is termed as the spathe. The whole spathe and flowers
are used to make containers for picnics [44]. The dead inflorescence is used to make brooms
[45]. The young flowers with spathe are full of sap, which is used to make “Kalou” drink
after the fermentation of extracted sap [46].
17.6.4
Potential of Coconut Fruits
Coconut flesh is a very significant natural laxative enriched with protein. It is used to make
coco milk, coco flour, candies, copra, coco chips, and animal feeds. Also it is used to make
several sweets and is a salad ingredient. Water inside the fruit is enriched with ascorbic acid,
proteins, and vitamin B [47]. Also it is used as a main ingredient for salad and other sweet
delicacies [48]. Coconut oil is a natural moisturizer, softener, and anti-wrinkle, avoids skin
contagion, and retains skin elasticity with enhanced skin tone. With the presence of longchain fatty alcohol and glycerol in coconut oil, it is utilized in the formulation of candles,
cosmetics, detergents, and soaps.
17.6.5
Usage of Coconut Milk
Coconut milk contains rich ingredients of saturated fat. It is used in Brazil to cook several
seafood dishes as well as baking of other dishes. The 1-week fermentation of coconut milk
and sugar by yeast directed to the manufacture of home beverage [49]. The well-known
cocktail Pina colada also has coconut milk as a component. It is also used all over Southeast
Asian communities in making curries.
17.6.6
Importance of Coconut Shell
The very hard outer cover of coconut fruits is called the coconut shell. These shells are
very in demand in making significant art items by handicraft industries nowadays. The
charcoal made from coconut shells is used in several localities and industries for various
purposes. Apart from several usage of activated charcoal, medicinally it is used for the
absorption of poisons and toxins. It is also used in making activated carbon. This activated carbon is safe and 100% natural, which is obtained by burning coconut shell in
various ways. It produces only very little ash after burning and does not cause pollution.
A whole lot of eco-friendly uses have made it preferable in many industries like manufacturing of air and water purifiers, odor eliminators, and even building golf courses.
The coconut shell powder is used in the production of mosquito coils and is very good in
timber industries due to its resistance to fungal and water outbreak.
278 Natural Oral Care in Dental Therapy
17.6.7
Commercial Usage of Husk Fibers
The long life of husk fibers has attracted the attention of several industries to make several
home and handicraft products. They are considered as they could normally survive for 20
years [50]. It is natural, eco-friendly, and safe. These fibers are basically used to make ropes
due to their longevity and resistance to water [51]. They are used to make fishing net, to
wash pots, as fuels, to make toys, in the production of mattresses, in irrigation arrangement
due to its water holding capacity, in hydroponic industries, to make mats, as an absorbent,
as automobile seats, to make concrete, to make brushes and brooms, in soil erosion, and as
an insulated material [52] due to its upright temperature holding strength.
17.6.8
Economic Importance of Coconut Stems
The main usage of coconut trunk is as a house building material. The wood is very durable
and is used to make tables, chairs, walls, doors, and window frames with other minor usage.
Coconut stems are used to make poles in telecommunication and other purposes. The
trunk is also used to produce wood planks, which are used in the partition of buildings to
make chambers. It is also valuable to make paper pulp.
17.6.9
Convention of Coconut Roots
The roots of this tree have been used traditionally for brushing the teeth, as mouth wash,
and for making dyes. The roots are also used to make beverage and various medicinal products. Roots are used to treat urinary tract contamination and gall bladder and kidney problems, to treat eczema, to omit blood clotting, and to stop painful hemorrhoidal bleeding in
the human body. It is very effective in skin disorders, itching of toes, fever, diarrhea, and
dysentery.
17.7 Active Constituent Identified from Coconut
The flower extract of coconut in different solvents led to the identification of several
classes of bioactive secondary metabolites, which include anthraquinones, alkaloids,
amino acids, carbohydrates, flavonoids, phenols, saponins, and tannins [53, 54]. The oil
obtained from the coconut shells is used for the treatment of skin disorders and abrasions.
This oil was extracted into the solvent of different polarity fractions, which were analyzed
for their phytochemicals, and show the way to the presence of alkaloids, amino acids,
carbohydrates, carboxylic acid, flavonoids, phenols, proteins, quinones, oxalate, tannins,
and terpenoids [55]. The oil obtained from the coconut mainly comprises triglycerides
mixture of saturated fatty acids with short to medium chain and limited amount of unsaturated fatty acids. Lauric acid, one of the chief components of coconut oil, holds about
50% of total composition [56]. Apart from the lauric acid, its composition includes arachidonic acid, capric acid, caproic acid, caprylic acid, eicosinoic acid, linoleic acid, linolenic
acid, myristic acid, oleic acid, palmitic acid, and stearic acid [57, 58]. This composition
of coconut oil is accountable for the strong antibacterial, antifungal, antiprotozoal, and
antiviral potential.
Coconut Palm (Cocos nucifera L.) 279
CH2
CH2
H 3C
CH3
H3CO
CH3
H3CO
H 3C
H3C
CH3
Lupeol Methyl Ether
CH3
Skimmiwallin
Isoskimmiwallin
CH3
HO
HO
H
CH3
H
CH3
CH3
OH
O
O
HO
OH
OH
Ascarbic Acid
a-tocopherol
NH
CH3
HO
O
OH
O
O
HO
OH
HO
CH3
O
CH3
CH2
CH3
CH3
H3C
H2N
N
H
OH
CH3
OH
NH2
Lauric Acid
L-Arginine
Catechin
O
O
HO
CH3
HO
CH3
Arachidonic acid
Capric acid
O
O
HO
CH3
HO
CH3
Linoleic acid
Caprylic acid
O
HO
CH3
CH3
CH3
COOH
CH3
H3CO
H 3C
CH3
H 3C
CH3
CH3
CH3
H 3C
H 3C
O
CH3
HO
CH3
Linolenic acid
Caproic acid
O
CH3
O
CH3
HO
HO
Oleic acid
Myristic acid
CH3
O
HO
CH3
O
HO
Stearic acid
Palmitic acid
17.8 Future Prospective
Coconut palm tree is distinguished for its therapeutic values as well as resourceful nourishments. Homemade and herbal formulations of coconut have extra plenteous devotion in
the last decade, which has been continued since the ancient time. There are many bioactive
280 Natural Oral Care in Dental Therapy
compounds that have been identified from coconut that exhibit significant pharmacological
properties including extraordinary potential to preserve and sustain strong teeth. Coconut
tree produces fresh coconut water, coconut milk, coconut oil, endosperms, husk fibers, leaves,
roots, and trunks. All these parts of coconut have their own significant values in innumerable
traditions. Coconut water is an important component to preserve periodontal ligament cell
viability and transport media to tear off tooth. It is also defined as a nutritional power booster
drink and has achieved international acclaim as a natural sport drink. It is a clear liquid containing various nutrients with electrolytic property. It improves the skin and reduces swelling,
and one gets better immune function and root canal irrigant via its antimicrobial potential.
Coconut oil has an amazing composition of saturated and unsaturated fatty acids, attributed
to the anti-microbial properties. An alcoholic extract of coconut as well as coconut oil shows
very good antibacterial potential against S. mutans including other oral bacterial species.
A previous literature reports on traditional, ethnopharmacological, pharmacological,
phytochemical, and valuable importance of coconut at different community levels; it is clear
that there is hitherto scantiness of scientific investigation with respect to the mode of action
inside the human body. However, a number of active metabolites have been identified and
there may still be many more unknown compounds that could be accountable for biological properties. Hereafter, more explorations are needed for the credentials of mysterious
metabolites and their respective bioactivity. Therefore, coconut tree could be of interest to
many researcher; they should consider this tree for future research to discover the unseen
facets of this enchanted tree.
17.9 Conclusions
The current section of this book compiles the economic usage of coconut tree in oral cavity
disorders. Apart from the significant potential to overcome on dental complications, we have
also summarized the other advantage of the coconut tree. Its traditional usage, ethnopharmacological relevance, pharmacological properties and identified phytochemical profile of
this plant have been compiled in this assignment. This tree is one of the most extensive species explored at the national and international level for its medical implication. More than
100 research articles have been published on C. nucifera tree. We have assembled all updates
on coconut tree in this chapter with documentation of potential secondary metabolites and
usage in dentistry. The designated evidences were composed of the several research articles
published on this plant and from internet sources. A very recent report proved its antidiabetic
potential in combination with metformin, a standard drug available in the market for diabetic
patients. Hence, additional study is compulsory to fix the unidentified aspects regarding the
coconut tree by organized examination and upscaling of the precise evidences. This chapter
will provide a platform to the researches to convey the supplementary steps in further research.
Acknowledgments
The authors gratefully acknowledge the University of Delhi, India for help and support.
University of Grant Commission (UGC), New Delhi, is also gratefully acknowledged for
the postdoctoral fellowship award of Dr. D.S. Kothari and for financial support.
Coconut Palm (Cocos nucifera L.) 281
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18
Salvadora persica L. (Miswak):
An Effective Folklore Toothbrush
Sujata P. Sawarkar1*, Anisha D’souza2 and Trinette Fernandes1
1
Department of Pharmaceutics, SVKM’s Dr. Bhanuben Nanavati College of Pharmacy,
University of Mumbai, Maharashtra, India
2
Formulation Development Laboratory, Piramal Enterprises Limited, Light Hall, Chandivali, Powai,
Mumbai, India
Abstract
Miswak (Misswak, meswak, miswaki, siwaki, sewak,) is one such ancient age-old extensively used
chewing stick obtained from Salvadora persica L (Arak Tree) or toothbrush tree. The shrub is commonly cultivated in Asia, Middle East, and Africa. Miswak is obtained from Salvadora persica from
the family Salvadoraceae. The plant has several phytoconstituents that have shown promising effects
in maintaining oral hygiene. The chemical constituents of Salvadora persica or Arak (Miswak)
include glycosides, flavonoids, resins, Benzyl isothiocyanate, volatile oils, terpenes, silica, and mineral salts. Miswak has several therapeutic activities, which include antibacterial, antifungal, anticariogenic, and anti-plaque effect and, hence, acts on the pathogens. The World Health Organization
has recommended more use of miswak for promotion and maintenance of oral health. Traditionally,
miswak is used as chewing sticks, but it is available in modern applications. The commercial products of miswak that are available are toothpastes, mouthwashes, irrigants, and chewing gums. It is
essential to promote the usage of miswak to promote oral hygiene and health care management.
Keywords: Miswak, oral hygiene, Salvadora Persica, volatile oils, Benzyl isothiocyanate
18.1 Introduction
Oral cavity is a major entry portal for many diseases affecting health. Poor maintenance
of craniofacial and oral health affects the psychosocial and functional quality of life. The
easy strategy of maintaining oral hygiene is mechanical cleaning of tooth using dentifrice
and toothbrush [1]. Natural and medicinal plants are complementary therapy due to their
numerous beneficial effects [2]. Natural cleansers include chewing sticks from anti-microbialexhibiting shrubs, plants, and trees [3] instead of the currently used plastic-bristle brushes.
Miswak (Misswak, meswak, miswaki, siwaki, sewak) is one such ancient age-old extensively
used chewing stick obtained from Salvadora persica L (Arak Tree) or toothbrush tree. The
*Corresponding author: sujata.sawarkar@bncp.ac.in; sujatasawarkar19@gmail.com
Durgesh Nandini Chauhan, Prabhu Raj Singh, Kamal Shah, and Nagendra Singh Chauhan (eds.)
Natural Oral Care in Dental Therapy, (285–296) © 2020 Scrivener Publishing LLC
285
286 Natural Oral Care in Dental Therapy
entire plant, i.e., the twigs, roots, and stems have been used as chewing sticks for oral hygiene.
This shrub is commonly obtained in Asia, Middle East, and Africa [4]. Miswak brushes are
obtained from the roots of the Arak tree and can be used on the teeth and gums. The plant
exhibits anti-bacterial and anti-fungal properties against those bacteria and fungi responsible for the development of periodontitis and dental plaque [5]. These chewing sticks are
chewed till they are frayed brush-like form and can be used as brush for cleaning. After multiple use, the chewing stick brush gets shredded and becomes ineffective. The chewing stick
miswak exerts efficacy due to the fiber’s mechanical effect as well as the release of vitamin C,
trimethyleamine, resins, saponins, salvadorine, flavodine, and sterol [6]. The present chapter
discusses about Salvadora persica L (Miswak), known in ancient times, and the current scientific understanding of varied Miswak (Salvadora persica L) activities.
18.2 History
The use of mechanical devices for cleaning teeth has been a folklore tradition. The exact
inception is unknown. Toothpicks have been known to originate from the Babylonians and
used along with other toiletry articles to remove or clean the fibrous residue retaining between
the teeth after meals. While the Romans also used mastic tree-originated toothpicks (Pistacia
lentiscus), the Arabs used miswak or siwak. The importance and use of meswak has also been
incorporated as a religious practice in Islam. The use of miswak has been suggested before
and after sleeping, before and after having meals, after entering house, during fasting, and
before reading or reciting prayers or holy texts. Hence, it is more popular among the Muslims
globally [7]. Miswak is obtained from Salvadora persica from the family Salvadoraceae. It is an
evergreen shrub, which grows up to a maximum of 3 m. The fruits are edible berry and barely
noticeable. It can tolerate extreme conditions, dry environments, as well as saline soils [8].
18.3 Chemical Constituents
The chemical constituents of Salvadora persica or Arak (Miswak) include glycosides such
as Salvadosides and Salvadorasides, flavonoids [9]. Silica present in miswak has abrasive
effect on stains. Resins present in miswak provide protective effect on tooth enamels. Other
prominent phytoconstituents are Benzyl isothiocyanate, volatile oils, terpenes. Alali F. et al.
performed GC MS analysis to identify the components of the oils. The constituents identified were 1,8-cineole (eucalyptol), α-caryophellene, β-pinene (6.3%), and 9-epi-(E)
caryophellene [10].
Benzyl isothiocyanate has a potent activity against dental caries. M.S. Abdel-Kader et al.
quantified benzyl isothiocyanate in root extracts of Salvadora persica by gas chromatography (GC) [11]. In addition to benzyl isothiocyanate, miswak also contains benzyl nitrile,
carvacrol, aniline, benzaldehyde, naphthalene [12].
The root bark of miswak contains chlorine. In addition, it contains lauric acid, palmitic, and myristic acid and lignin derivatives of phenols and furans, syringins, liriodendrin, and sitosterol-O-glucopyranoside [12]. Chlorine acts as dentrifice to remove tartar.
−
Antimicrobial substances present in miswak are sulfate SO2−
4 and thiocyanate SCN . SCN− is
acted upon by lactoperoxidase present in the saliva in the presence of hydrogen peroxide to
Salvadora persica L. (Miswak) 287
form hypothiocyanate (OSCN−). Hypothiocyanate interacts with bacterial enzymes leading
to cell death. β-Sitosterol and ascorbic acid show anticholesterolemic properties. Ascorbic
acid (Vitamin C) showed an antiscorbutic activity. Trimethylamine and Salvadorine have
shown potent antibacterial and gingiva-stimulating effects. The presence of trimethylamine,
alkaloid resin, and sulfur compounds has shown potent antimycotic effect.
Halib et al. performed morphological and elemental analysis of fibers of Salvadora persica. Energy-dispersive X-ray spectroscopy (EDX) and scanning electron microscopy was
used to identify mineral crystals present in these fibers. The rhomboidal crystals were composed of O, C, S, Ca, Na, and K, whereas the irregular crystals consisted of C, O, Al, Si, S,
K, Ca, and Fe [13].
Mohamed et al. investigated the presence of five α-amylases in miswak. The methodology
adopted for purification was chromatography on DEAE Sepharose column and Sepharyl
S-200 column and molecular weight determination by Gel filtration and SDS-PAGE. The
five α-amylases identified were A1, A4a, A4b, A5a, and A5b. The researchers concluded
that the presence of Ca2+ activated the enzymes, whereas Ni2+, Co2+, and Zn2+ activated or
inhibited the enzymes [9].
18.4
Extraction, Isolation, Identification of Chemical Constituents
Benzyl isothiocyanate is obtained as an essential oil by steam distillation. Gas chromatographymass spectrometry confirmed the presence of benzyl isothiocyanate. It has a better cidal
effect on gram-negative periodontal pathogens like A. actinomycetemcomitans, P. ginigivalis,
Salmonella enterica, Haemophilus influenzae, etc. The roots of Miswak is cut and ground using
stone mill and steam distilled at 80°C followed by extraction with hexane. Solid-phase microextraction of Miswak was also used for collecting the volatile Benzyl isothiocyanate using
polydimethylsiloxane/divinylbenzene-coated SPME-fibers. The volatile oil was characterized
by GC-MS and TLC [14]. Benzyl isothiocyanate composed 73.8% of volatile oil, while benzyl
nitrile was 26.2%. The roots are devoid of any terpenes or hydrophobic chemicals [15].
18.5 Pharmacology—Therapeutic Activity of Salvadora persica L.
18.5.1
Theories for Miswak Activities
Mechanical cleaning of the chewing stick as toothbrush is one of the major reasons for cleaning teeth. Besides, the chemical constituents, Miswak exhibits antibacterial, antifungal, anticariogenic, and anti-plaque effect and, hence, acts on the pathogens disturbing the oral health.
Another reason is the constant chewing of sticks, which increases salivation and also the chloride and calcium content with reduced phosphate and pH immediately after the chewing.
This effect is not observed after 4 h of chewing. Calcium promotes the tooth enamel to mineralize, while chloride minimizes the formation of calculus [16]. Also, miswak extract elevated
the plaque pH and also stimulated secretions from the parotid gland within 30 min of rinsing
the oral cavity with the extract. Increasing the secretions increases the plaque pH and thus
prevents caries [17]. Reports of antioxidant activity attributed to the various enzymes (catalase, peroxidase, polyphenol oxidase, etc.) and compounds like phenol, tocopherols [18],
288 Natural Oral Care in Dental Therapy
beta-sitosterol, stigmasterol [19] in seed oil, and cake of Salvadora persica are synergistic for
cleaning teeth [20]. A combination of miswak with other herbal extracts like kalonji and aloe
vera provided synergestic effect as antimicrobial, antioxidant, and anti-proliferative [21].
18.5.2
Antibacterial and Antifungal
The ethanolic extracts have shown a higher antimicrobial activity. Among the different parts—
root, twig, stem, it was found that the alcoholic root extract was more effective than the extract
from the twig, and the least effective was the aqueous extract from the stem [22]. In vitro studies of miswak have shown antifungal and antibacterial effects on periodontal pathogens and
cariogenic bacteria. They have been effective against both aerobic and anaerobic bacteria [23–
29]. Clinical studies additionally have shown that 10% of the aqueous extract of Miswak can be
effectively used only if it is used as an irrigant clinically during endodontic therapy where the
teeth have necrotic pulps [30–33]. However, the antimicrobial effect of crude miswak extract
was low to moderate in comparison to tea tree oil and 0.2% aqueous chlorhexidine [22].
Zayed Al-Ayed et al. evaluated the antibacterial activity of Salvadora persica (Miswak)
extracts against multidrug-resistant bacteria obtained from clinical isolates. Methanolic
extracts of miswak showed a promising effect against methicillin-resistant Staphylococcus
aureus, Acinetobacter baumannii, and Stenotrophomonas maltophilia. In vitro studies of
Miswak on 10 multidrug-resistant (MDR) bacterial clinical isolates excluding the oral pathogens have also been studied. These included a) methicillin-resistant Staphylococcus aureus,
b) penicillin-resistant Streptococcus pyogenes, c) Klebsiella pneumoniae, d) Pseudomonas
aeruginosa, e) Escherichia coli, f) Acinetobacter baumannii, g) Serratia marcescens,
h) Stenotrophomonas maltophilia, i) methicillin-resistant Staphylococcus epidermidis, and
j) Enterococcus faecalis. Activity was checked by agar diffusion as well as minimum inhibitory concentration method. The methanolic and water extracts were effective against all the
MDR pathogens at concentrations of 400 mg/mL on all the strains, with methanolic extract
being more effective than the aqueous extracts. The antibacterial effect was more prominent
than the Gram-positive bacteria. The minimum inhibitory concentration was 0.39 mg/mL
for Escherichia coli using the methanolic extract, while it was 1.56 mg/mL with the aqueous extract. Methicillin-resistant Staphylococcus aureus, Stenotrophomonas maltophilia, and
Acinetobacter baumannii had high MIC of 12.5 mg/mL with the aqueous extract and 6.25
mg/mL with the methanolic extract. Vancomycin and Tobramycin were used as positive
controls at concentrations of 30 µg/mL and 10 µg/mL, respectively [34].
The most probable reason could be that the methanolic extract has the capability of
extracting flavonoids, tannins, alkaloids, sterols, and other reducing agents. However, aqueous extracts also have saponins, reducing components, and tannins [29]. Benzyl isothiocyanate is another volatile compound identified in the extracts, which have a quick and strong
cidal effect against Gram-negative periodontal pathogens compared to the Gram-positive
bacilli. The volatile ingredient could penetrate easily through the bacilli membrane and
interfere with the redox systems failing to maintain the membrane potential [31]. Another
such active ingredient of Salvadora persica is N-benzyl-2-phenylacetamide with moderate antimicrobial activity. At a concentration of 87 µL of N-benzyl-2-phenylacetamide,
the activity was equivalent to 20 µL of gentamycin [35]. The results were, however, seen
opposite to those studied with oral pathogens. With oral pathogens, the aqueous Miswak
extract exhibited higher antimicrobial effect than the methanolic extracts. The oral
Salvadora persica L. (Miswak) 289
pathogens studied were Candida albicans, Lactobacillus acidophilus, Pseudomonoas aeruginosa, Staphylococcus aureus, Streptococcus faecalis, Streptococcus mutans, and Streptococcus
mutans. Streptococcus responded very quickly to aqueous extracts and exhibited an inhibitory activity against Streptococcus faecalis [36]. Simple addition of whole miswak pieces
inside the agar or simply suspended above the agar plate exhibited an antibacterial effect
against bacteria like Aggregatibacter actinomycetemcomitans, Haemophilus influenzae,
Lactobacillus acidophilus, Poryphyromonas gingivalis, and Streptococcus mutans found
during caries progression and periodontitis [37].
A comparison of different herbal extracts from Avicennia marina (Qurm), Aspho delustenui
foils (Kufer), Fagonia indica (Shoka’a), Portulaca oleracea (Baq’lah), Lawsania inermis (henna),
Salvadora persica (Souwak), and Ziziphus spina-Christi (Sidr) was studied with respect to
the stability and toxicity, different dynamic growths of Candida albicans accompanied with
secondary bacterial infections. Candida albicans have a complicated morphology switching
between yeast and hyphae to form resistant biofilm harboring secondary bacilli. The dried
ethanolic extracts of these plants were reconstituted with water before administration. The
alcoholic extracts of S. persica, L. inermis, and P. oleracea significantly inhibited Candida albicans growth after 24 h and 72 h of incubation in liquid Luria–Bertani media, while it showed
moderate antibacterial effect against secondary infection-related bacilli [38]. Salvadora persica extract showed superior activity against Lactobacillus acidophilus compared to Neem,
which showed higher activity against Streptococcus mutans than the former [39]. An in vitro
comparison of miswak extract, an Iranian toothpaste containing miswak extract, and another
toothpaste from Switzerland also containing miswak extract was studied on Eikenella corrodens, Streptococcus sanguis, Porphyromonas gingivalis, and Streptococcus salivarius. All of them
showed inhibition of dental plaque bacteria [40]. However, the presence of toothpaste containing miswak extract was more beneficial in Streptococcus mutans reduction compared to simple
brushing. Lactobacilli were, however, not that affected [41]. The antibacterial effect of Miswak
mouthwash (PersicaTM, Pursina Pharmaceutical Company, Tehran, Iran) though was effective
against Streptococcus mutans; it was, however, not that potent as Chlorhexidine in orthodontic
patients [42]. Moreover, Miswak mouthwash was found to be more effective in reducing the
levels of Lactobacilli compared to ordinary toothwash within 2 weeks of use. The mouthwash
was better than Miswak toothpaste also [43–45]. The effect was also pronounced than saline
but not beyond 2 weeks [46]. Further addition of yarrow extracts and mint decreased the
counts of Enterococcus faecalis and Candida albicans significantly in vivo [47].
In one study, it was observed that the antibacterial effect of fresh Miswak, 1-monthold miswak was unaffected [48]. The activity was found to be unaffected after 18 years
of storage. The old Miswak extract demonstrated activity against Streptococcus faecalis
[49]. Meanwhile, the antifungal effect of acetone extracts of (300 mg/mL) the dry stems
of Salavadora persica had higher activity against Candida strains of Candida glabrata,
Candida albicans, and Candida parapsilosis, while the methanolic and ethyl acetate extracts
were effective on only one strain of the isolate [50]. Surprisingly, the dried Miswak was
more effective as an antifungal rather than the fresh plant. The aqueous extract of the roots
were antimycotic at concentrations greater than 15% for up to 48 h on Candida albicans
[51]. Besides Candida albicans, a number of references cite about the antifungal activity of
Salvadora persica against Enterococcus faecalis [52], Aspergillus strains [53, 54]. There have
been mixed reports about efficacy of ethanolic extracts against Candida clinical isolates
[54], while some researchers have reported strong to moderate activity [55–57].
290 Natural Oral Care in Dental Therapy
18.5.3
Anti-Viral Effect
BITC extracted from roots (133 µg/mL) have shown virucidal effect against Herpes simplex
virus-1 [51].
18.5.4
Anti-Cariogenic Effect
Miswak has strong anti-decay effect with reduced plaque formation and development and
thereby poor progression of caries in miswak adult users [58]. Besides, the rural population with a high tendency to use miswak exhibited lower caries prevalence compared
to the urban population of Zanzibar [59]. The antidecay effect is attributed to its fluoride
content [60, 61]. Besides, salivary secretion increases due to the chewing effect and hot
taste of miswak, which subsequently increases the buffering capacity [62]. A clinical trial
performed on second-year Iranian school children showed that miswak was able to prevent
dental caries. The control group, using only toothbrush for cleaning, was 9.35 times more
prone for the risk of dental caries [63]. Fortified fresh miswak chewing sticks with sodium
fluoride have a remineralizing effect on the white spot lesions [64, 65].
Al-Dabbagh et al. compared the efficacy of Miswak toothpaste and mouthwash with other
commercial dental products on cariogenic bacteria. The studies concluded that Miswak
products especially mouthwash showed more efficacy against Lactobacilli and Streptococcus
mutans than other products [66].
18.5.5
Antiplaque Effect
Miswak significantly reduced buccal and lingual gingivitis following brushing with Miswak
five times a day compared to brushing with a conventional toothbrush. Brushing twice a
day though showed significantly reduced buccal ginigivitis, but the effect was not much
pronounced with lingual surfaces [67]. It is also effective against plaque [68] and dental caries [69] than tooth brushing. A research also reported that a toothpaste containing Salvadora persica was more effective than commercial toothpaste for plaque removal
[62]. A single-blind, randomized clinical study showed that miswak was better in reducing
Aggregatibacter actinomycetemcomitans in subgingival plaque [68]. A double blinded randomized trial of Salvadora persica extract chewing gum was conducted in volunteers having
moderate gingivitis, reduced plaque index, bleeding index, and gingival index [70].
In one study, researchers performed a 24-h plaque re-growth, double-blinded randomized
controlled crossover trial wherein they compared a Miswak and Green Tea combination mouthwash with Chlorhexidine mouthwash [71]. The plaque activity was measured by the modified
Quigely Hein plaque index. The Miswak and Green tea combination mouthwash showed significant reduction in plaque accumulation compared to the placebo and Chlorhexidine mouthwash.
18.5.6
Antiperiodontitis Effect
Clinical studies have shown that Miswak users showed fewer incidences of dental calculus and gingival bleeding. M. Hammad and A. K. Sallal studied the effect of mouth rinse
with aqueous Salvadora twigs extract and Chlorhexidine digluconate on the adhesion of
Streptococcus mutans bacterial cells to buccal epithelial cells [72].
Salvadora persica L. (Miswak) 291
18.5.7
Whitening Effect
Salvadora persica (Miswak) extracts have shown potent whitening effect. Halib et al. evaluated the anti-staining activity of Miswak on extracted premolar teeth. The stains were
developed using tea and coffee. The researchers formulated Miswak paste and compared
it with commercial whitening toothpaste. The changes in teeth shade were assessed using
VITAPAN Classical Shade. Miswak toothpaste showed a promising whitening effect.
The whitening effect was attributed to the abrasive effect caused by silica and mineral
crystals [73].
The therapeutic effects attributed by various constituents present in Salvadora persica
(Miswak) are summarized in Table 18.1.
Table 18.1 Phytoconstituents of Salvadora persica (Miswak) and their therapeutic activity on oral
hygiene [74].
Sr. no.
Phytoconstituent
Therapeutic activity
1.
Silica
Abrasive−removes plaque and stain
2.
Tannins (Tannic acid)
Alleviates gingivitis
Antifungal activity especially Candida albicans
3.
Resins
Forms protective layer on enamel surface, provides
protective effect against dental caries
4.
Alkaloids (Salvadorine)
Antifungal, bactericidal, and gingival stimulatory
effect
5.
Essential volatile oils
Antibacterial effect and stimulate saliva
6.
Sulfur
Bactericidal effect
7.
Vitamin C
Antiscorbutic, healing, and tissue repair
8.
Sodium bicarbonate
Mild abrasive, dentifrice
9.
Calcium
Prevention of demineralization, induction of
remineralization of enamel
10.
Fluoride
Anticariogenic activity and tooth remineralization
11.
Chloride
Prevention of formation of tartar, calculus
12.
N-benzyl-2phenylacetamide
Inhibits human collagen-induced platelet aggregation
and antibacterial activity against Escherichia coli.
13.
Benzyl isothiocyanate
Chemo-preventive agent, bactericidal activity,
virucidal activity
14.
Trimethylamine
Antibacterial, antiphlogistic, and gum stimulating
effects
292 Natural Oral Care in Dental Therapy
18.6 Conclusion
Miswak has a good antibacterial and antifungal effect. The World Health Organization also
promotes the use of miswak sticks for improving oral hygiene [75]. Extensive investigations and standardization of the extracts to study for its effect against various pathogens are
required. Gingival recession (gingival recession index score) due to mechanical trauma is a
main disadvantage of Miswak usage [76]. Accessibility of Miswak toothbrush to the entire
tooth area limits the function of the stick during cleaning of the teeth. It is essential that
miswak sticks should be designed in a manner to maximize the exposure of the chewing
stick to the lingual surface and interdental spaces. For better oral hygiene, miswak should
be promoted as an adjunct to traditional toothbrush not only due to its low cost and easy
availability but because of its therapeutic effects also. Application of modern science and
technology to develop contemporary dosages to avail optimum clinical benefits from this
versatile, indigenous plant is the need of the hour.
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19
Triphala and Oral Health
Kamal Shigli1*, Sushma S Nayak2, Mrinal Shete3, Vasanti Lagali Jirge4
and Veerendra Nanjwade5
1
Department of Prosthodontics, D.Y. Patil Dental School, Lohegaon, Pune, Maharashtra, India
2
Public Health Dentist, Bangalore, Karnataka, India
3
Department of Oral Pathology, D.Y. Patil Dental School, Lohegaon, Pune, Maharashtra, India
4
Department of Oral Medicine and Radiology, KLE VK Institute of Dental Sciences, Belgavi,
Karnataka, India
5
Formulation Development, Unichem Laboratories Limited, Bangalore, India
Abstract
“Triphala” is a popular combination of three fruits, namely, Emblica officinalis (Amalaki), Terminalia
chebula (Haritaki), and Terminalia bellerica (Bibhitaki) in equal proportions. The combination
exerts several therapeutic effects on oral health, including anti-caries, antioxidant, anti-microbial,
and anti-candida activities. It inhibits the growth of S. mutans. Tannic acid, which is one of the main
components of triphala, is responsible for this effect. Triphala exhibits an antiplaque efficacy, which
is almost equivalent to that of chlorhexidine. It has been suggested as an alternative to sodium hypochlorite (NaOCl) for irrigation of root canal. Triphala also exerts protective effect on gingival health.
Thus, triphala could be an adjuvant to conventional drugs for overall improvement of oral health.
Keywords: Triphala, oral health, dentistry, dental caries, periodontitis, candidiasis, oral cancer,
root canal medicament
19.1 Introduction
“Triphala’ is a popular herbal combination of three fruits namely Terminalia chebula,
Terminalia bellerica, and Emblica officinalis or Phyllanthus emblica in equal proportion
[2, 3]. These three myrobalans are also called as Harada, Bahera, and Amla, respectively, in
vernacular language [2] (Figure 19.1). Triphala has about 47 tannins and 35 phytochemicals
[2]. It could be used to treat various diseases of oral cavity with minimal or no side effects
on oral tissues at a minimal cost compared to existing dentifrices.
*Corresponding author: kamalshigli@yahoo.co.in
Durgesh Nandini Chauhan, Prabhu Raj Singh, Kamal Shah, and Nagendra Singh Chauhan (eds.)
Natural Oral Care in Dental Therapy, (297–312) © 2020 Scrivener Publishing LLC
297
298 Natural Oral Care in Dental Therapy
Triphala
Terminalia chebula
(Haritaki)
Terminalia bellerica
(Bibhitaki)
Emblica officinalis or
Phyllanthus emblica
(Amalaki)
Figure 19.1 Diagrammatic representation of components of Triphala.
19.2 Taxonomical Classification
Terminalia chebula (Genus: Terminalia, Family Combretaceae) is commonly available in
India, Sri Lanka, and Burma [1, 2, 4].
Terminalia bellerica (Genus: Terminalia L, Family Combretaceae) is found mainly in
central Asia [1, 2].
Emblica officinalis (Genus: Phyllanthus, Family Euphorbiaceae) is a medium-to-large
tree growing in India, Pakistan, China, Malaysia, and Thailand [2, 5].
19.3 Chief Phytoconstituents
Triphala mainly contains Tannins; Quinones; Flavones, flavonoids, and flavonols; Gallic
acid and Vitamin C (Figure 19.2) [1].
Tannins
Tannins are polymeric phenolic substances. They possess astringent property
(ability to precipitate gelatin from solution) [1]. They exhibit anti-infective
properties by deactivating microbial adhesins, enzymes, and cell envelope
transport proteins [1, 2].
Quinones
Quinones are aromatic rings (with two ketone substitutions) and are highly
reactive. They are an initiator of stable free radicals [1, 2]. Anti-microbial
effect of quinones results from inactivation of protein and loss of function
caused by combining with the nucleophilic amino acids [1, 2]. Another
mechanism is by making the substrates unavailable to the organisms [1, 2].
Triphala and Oral Health 299
Terminalia chebula
(Haritaki)
Tannin, chebulic
acid, chebulagic
acid, corrilagin, and
gallic acid
Anti-caries
Antioxidant
Efficient for
gingivitis
Antifungal
Terminalia bellerica
(Bibhitaki)
Emblica officinalis or
Phyllanthus emblica
(Amalaki)
Gallic acid, tannic
acid, and glycosides
Vitamin C, carotene,
nicotinic acid,
riboflavin, phenols,
polyphenols,
flavonoids, kaempferol
and tannins
Most active
antioxidant
Antifungal
Cariostatic effect
Antioxidant
Gingivitis
Antifungal
Figure 19.2 Chief constituents of Triphala with their effect on the oral cavity.
Flavones, flavonoids and flavonols
Flavones are phenolic structures having one carbonyl group [1]. Adding a
3-hydroxyl group results in the formation of a flavonol. Flavonoids are
produced against microbial infection and are effective against a range of
organisms, as they bind with extracellular proteins [1, 2]. They also have
the potential to bind with, disrupt bacterial cell walls and membranes thus
exhibiting inhibitory effect on bacteria like Streptococcus mutans in in vitro
conditions [1, 2].
Gallic acid
Gallic acid is an antioxidant present in all constituents of Triphala [1, 2]. It possesses hepatoprotective, antioxidant activity, and suppresses growth of cancer
cells [1].
Vitamin C
Vitamin C is an antioxidant, and it hastens the healing process along with flavonoids [1, 2]. Emblica officinalis (EO) is rich in vitamin C and accounts
for approximately 45–70% of the antioxidant activity exhibited by triphala
[1, 2, 5].
Emblica officinalis (Amalaki) also contains carotene, niacin, vitamin B2, phenols, polyphenols, flavonoids, kaempferol, and tannins [1, 2, 5]. It has gallic acid derivatives like epigallocatechin gallate [2].
Terminalia chebula (Haritaki) has high tannin content, chebulic acid, chebulagic acid,
corrilagin, and gallic acid [1, 4].
Terminalia bellerica (Bibhitaki) contains mainly ellagic and gallic acid. Other constituents are termilignan, anolignan B, β-sitosterol, arjungenin, belleric acid, bellericosidem,
300 Natural Oral Care in Dental Therapy
flavonoids, saponins, amino acids, polyphenol, quinine, coumarin, glucosides, carbohydrates, alkaloids, ethylgallate, gallylglucose, chebulanic acid, and tannins [1, 2].
19.4 Role of Triphala in Dentistry (Table 19.1)
19.4.1
Anti-Caries Activity
T. chebula extract has demonstrated activity against dental caries, inhibiting the growth of
S. mutans on the tooth surface, thus, reducing accumulation of acids and resulting demineralization and breakdown of tooth structure [1, 2, 6]. This activity could be due to tannins and flavonoid present in it [2]. Tannins exert cytotoxic action on the cell membranes
of the microorganisms [2]. The astringent character of tannins inhibits electron transport
system and causes complexation with enzymes or substrates [2]. Flavonoids, which are a
group of phenols, are anticariogenic by the presence of antiglucosyl-transferases activity
[2]. The therapeutic ingredients of E. officinalis bind to the surface of bacteria resulting
in a decrease in the adherence of S. mutans to the surface of the tooth [2]. Also, the virulent genes that contribute to aggregation of plaque components are suppressed resulting in decreased caries of dental tissues [2]. Triphala extract prevents the formation of
plaque on the tooth surface because of inhibition of sucrose-induced adherence and the
glucan-induced aggregation, which mainly favors bacterial colonization on the tooth
surface [1, 6].
The constituents of E. officinalis together exert a major cariostatic effect [2]. Individual
constituents of E. officinalis may not be as potent as the whole composition [2].
The mixed herbal powder extracts (MHPE) containing Acacia arabica with Triphala
retard the growth of cariogenic microorganisms at a very low concentration compared to
chlorhexidine [7].
19.4.2
Triphala as a Root Canal Irrigant
Sodium hypochlorite (NaOCl) is a popular root canal irrigant. It removes debris, dissolves
tissue remnants, disinfects the root canals, and removes E. faecalis biofilms. However, it
has certain disadvantages like displeasing taste, high toxicity, and its inability to eliminate
the smear layer. Compared to this, Triphala has shown strong antibacterial activity against
3-week and 6-week biofilms. The use of herbal agents for irrigation of root canals could be
more beneficial as they seem to lack adverse effects [1].
Thomas et al. compared the antimicrobial efficacy of diode laser, triphala, and sodium
hypochlorite against Enterococcus faecalis-contaminated primary root canals and concluded that Triphala could be used as an alternative disinfectant to Sodium hypochlorite (NaOCl) as it exhibited better antibacterial efficacy than Sodium hypochlorite [8].
Divia et al. concluded that Triphala exhibited antibacterial activity almost like that of
NaOCl [9].
Another study found that the use of triphala juice as a root canal irrigant resulted in
significant reduction in colony-forming units of E. faecalis and Candida albicans 1 day after
irrigation compared to chlorhexidine, which inhibited the counts up to 3 days post irrigation in vitro [10].
Table 19.1 Depicting clinical studies and their outcome.
Triphala or
component used
Duration of study
Outcome measures
Significant findings
Usha et al.
(2007) [15]
T. chebula aqueous
extract
Immediate, 10 min, 30
min, 1 h
Salivary pH, buffering
capacity, &
microbial activity
Salivary pH, buffering capacity were higher
than baseline up to 30 min after use of T.
chebula mouthrinse. Streptococcus mutans
and lactobacillus count reduced by 65% and
71%, respectively post rinsing.
Nayak et al.
(2010) [16]
T. chebula aqueous
extract
Immediate
Salivary pH & salivary
S. mutans count
Rinsing with T. chebula aqueous extract led to
an increase in salivary pH, which remained
high up to 60 min post rinsing. Salivary S.
mutans count remained significantly low 5
min after rinsing. 60 min post rinsing sample
also showed reduction in S. mutans however
the difference in study and control group was
not significant.
Tandon et al.
(2010) [17]
Triphala mouthwash
3, 6, 9 months
Caries status (DMFS
scores) & Incipient
caries (DSi index)
The DMFS scores did not differ significantly
at follow up when Triphala & chlorhexidine
mouthwash groups were compared. There
was no significant increase in incipient caries
in Triphala group.
Srinagesh et al.
(2011) [18]
Triphala
Mouthwash
15 & 45 days
Salivary mutans
Streptococci
A reduction of 83% and 67% in Mutans
streptococci was observed in triphala group
after 15 days and 45 days, respectively.
Antimicrobial action of triphala was almost
equivalent to chlorhexidine.
(Continued)
Triphala and Oral Health 301
Authors
Authors
Triphala or
component used
Duration of study
Outcome measures
Significant findings
Bajaj et al.
(2011) [19]
Triphala mouthwash
Baseline, 3, 6 & 9
months
Plaque scores,
gingival scores &
microbiological
analysis
(Streptococcus &
lactobacilli counts)
Use of Triphala and chlorhexidine mouthwash
led to a reduction in, plaque scores and
Gingivitis scores, and also reduction
in growth of Streptococcus mutans
and Lactobacillus. In comparison to
chlorhexidine, Triphala had more inhibitory
effect on Lactobacillus, however the
difference was not significant.
Srinagesh et al.
(2012) [20]
Triphala mouthwash
48 h & 7 days
Streptococci colony
forming units
A reduction of 17% and 44% was observed in
oral Streptococcus colonies after 48 h and 7
days of triphala mouthwash use.
Nayak et al.
(2012) [4]
T. chebula ethanol
extract
Immediate
Salivary S. mutans
counts
Reduction of around 44% and 64% in S. mutans
counts was observed 5 and 60 min after
rinsing with ethanol extract of T. chebula.
Narayan et al.
(2012) [21]
Triphala, Hi Ora,
Chlorhexidine, &
Colgate Plax
28-day washout period;
1 day
Plaque formation
Triphala and Hi Ora presented an anti-plaque
efficacy similar to chlorhexidine and proved
more effective than Colgate Plax mouthwash.
Bhattacharjee
et al. (2014)
[22]
Triphala aqueous
extract
Baseline & follow-up
for 2 weeks
Plaque & Gingival
indices in children
Triphala and chlorhexidine mouth rinses
showed significant reduction of plaque and
gingival scores at follow-up.
Shetty et al.
(2014) [23]
Triphala Churna
Effect of single use
Total candida count
Triphala Churna was as effective as denture
cleansing tablet against Candida.
(Continued)
302 Natural Oral Care in Dental Therapy
Table 19.1 Depicting clinical studies and their outcome. (Continued)
Table 19.1 Depicting clinical studies and their outcome. (Continued)
Duration of study
Outcome measures
Significant findings
Naiktari et al.
(2014) [11]
Triphala mouthwash
1st, 15th day
Plaque index (PI) &
Gingival index (GI)
Triphala mouthwash reduced plaque
accumulation and gingival inflammation,
preventing periodontal disease. Its efficacy
as an antiplaque agent was similar to
Chlorhexidine.
Chainani et al.
(2014) [24]
Triphala extract
mouthrinse
Three phases of 1-month
duration each
Plaque index &
Gingival index
The antiplaque and antigingivitis activity of
triphala was almost equal to chlorhexidine.
Gupta et al.
(2014) [25]
Terminalia chebula
mouth rinse
Baseline, 7 & 14 days
Plaque; gingivitis
indices; Salivary pH
This study demonstrated that use of Terminalia
chebula mouth rinse led to a decrease in
plaque and gingivitis scores.
Pradeep et al.
(2016) [26]
Triphala mouthwash
Baseline, 7, 30 & 60
days
Plaque index; gingival
index; oral hygiene
index-simplified;
and microbiologic
colony counts
Use of Triphala mouthwash reduced gingival
index scores and was comparable to that of
chlorhexidine group.
Mamgain et al.
(2017) [27]
Triphala and Ela
decoction
Baseline, 14th day, 21st
day
Plaque, Gingival
Index & Halitosis
percentage
reduction
Triphala and Ela decoction had similar efficacy
as chlorhexidine.
Sushma et al.
(2017) [28]
Triphala churna
Effect of single use
Total Candida counts
Mean candida counts were lower in triphala
group compared to chlorhexidine group.
Significant decrease in candida counts was
observed in triphala group.
(Continued)
Triphala and Oral Health 303
Triphala or
component used
Authors
Authors
Triphala or
component used
Duration of study
Outcome measures
Significant findings
Vinod et al.
(2017) [29]
Herbal (combination
of tulsi, neem,
triphala, &
turmeric)
Immediate, 7th, 14th
day
Microbial colonies
Chlorhexidine mouthwash was better at 7th
day, while on prolonged usage for 14 days
the herbal preparation was found to perform
much better than Chlorhexidine in reducing
the microbial colony count.
Saxena et al.
(2017) [30]
T. chebula;
T. bellerica; E.
officinalis; &
Triphala
5 min & 60 min
Colony Forming Units
(CFUs) of S. mutans
T. chebula, T. bellerica, E officinalis, and
Triphala mouthwash was effective in
reducing S. mutans counts but among all
Triphala mouthwash was more effective.
Baratakke et al.
(2017) [31]
Alcoholic extract of
Triphala
21 days
Plaque and gingival
status
Triphala extract mouth rinse proved effective in
reducing plaque accumulation and gingival
inflammation with no side effects.
Irfan et al.
(2017) [32]
Triphala mouthwash
Baseline, 1 week, 1
month, and 45 days
Gingival Index (GI)
and Plaque Index
(PI)
Reduction in plaque scores was similar in
Triphala and chlorhexidine groups. Slightly
higher reduction in gingival scores was
observed in triphala group.
Shah et al.
(2018) [33]
Herbal mouthrinse
(Oratreat)
containing
Terminalia chebula
2 weeks
Colony Forming Unit
count
Higher reduction in Streptococcus mutans
colony forming units was observed
in triphala group when compared to
chlorhexidine group.
Naiktari et al.
(2018) [34]
Triphala mouthwash
Sampling repeated after
every 2 h for 12 h
Colony forming units
On use of Triphala mouthwash a reduction in
the S. mutans counts was observed up to 4 h.
(Continued)
304 Natural Oral Care in Dental Therapy
Table 19.1 Depicting clinical studies and their outcome. (Continued)
Table 19.1 Depicting clinical studies and their outcome. (Continued)
Authors
Triphala or
component used
Duration of study
Outcome measures
Significant findings
Salivary Streptococcus
mutans count & oral
hygiene status
Prevention of plaque accumulation was
similar in garlic, Chlorhexidine gluconate,
and triphala groups. Triphala showed
decrease in plaque index scores. Slightly
higher reduction in plaque index scores was
observed in chlorhexidine group.
Triphala,
chlorhexidine
gluconate & garlic
extract mouthwash
1, 15, & 30 days
Safiaghdam et
al. (2018)
[36]
Review current
clinical trials—
effectiveness of
herbal products in
gingivitis
Data collected from
2000 until January
2018
Triphala was effective in controlling gingivitis.
Triphala and Oral Health 305
Padiyar et al.
(2018) [35]
306 Natural Oral Care in Dental Therapy
19.4.3
Anti-Microbial and Anti-Oxidant Effect of Triphala
In vitro studies have shown anti-microbial and anti-oxidant effects of Triphala by its inhibition of Streptococcus mutans at concentrations as low as 50 µg/ml [1]. Triphala is useful
in the management of periodontal diseases because of its antimicrobial and antioxidant
properties [2]. This could be attributed to the tannic acid content of Triphala. The tannic
acid gets adsorbed on the bacterial cells, leading to protein denaturation and bacterial cell
death [1].
Among the three constituents of Triphala, T. bellerica demonstrates the strongest antioxidant activity followed by E. officinalis and T. chebula [1].
19.4.4
Role of Triphala in Periodontal Diseases
Triphala possesses hemostatic, anti-inflammatory, analgesic, and wound healing properties. T. chebula is most effective in controlling gingivitis and gingival ulcers. On the other
hand, Emblica officinalis contains a large amount of vitamin “C”, which helps in maintaining
healthy gingiva and prevents gingivitis and bleeding [11].
Another study reported that triphala or metronidazole, provided partial relief to the
patients with periodontal disease, and when combined and used, they demonstrated
a synergistic effect. They recommended triphala and metronidazole as a combined
treatment regimen for local (i.e., as mouth rinse) as well as systemic administration
[12].
19.4.5
Triphala as a Mouth Rinse
The use of Triphala mouth rinse with scaling and root planing resulted in significant reduction in plaque, gingival, and oral hygiene indices at 1 week, 4 weeks, and 6 weeks, similar
to the results obtained when chlorhexidine mouth rinse was used with scaling and root
planing [1].
19.4.6
Anti-Candida Activity of Triphala
The ethanol extract of P. emblica inhibited the adhesion of C. albicans to human buccal epithelial cells and acrylic surfaces of dentures in in vitro studies [5]. The mechanism for impediment of adhesion may be due to tannins, lignans, flavonoids, alkaloids, and other phenolic
compounds [5]. Compared to Aloe vera (50%), Triphala (12.5%) inhibited the growth of
Candida albicans at a lower concentration [13]. T. chebula and T. bellerica are mainly responsible for the antifungal activity [13].
19.4.7
Anti-Collagenase Activity of Triphala
Triphala slows the polymorphonuclear neutrophils (PMNs)—type matrix metalloproteinase, which are involved in the extracellular matrix (ECM) degradation during periodontitis
[1, 14].
Triphala and Oral Health 307
19.5 Pharmacological Activities of Triphala and Future Research
All the three components of triphala have various beneficial effects on human health, when
used alone and also when used in combination. The pharmacological activities of triphala
and its constituents are as follows:
19.5.1
Anticancer and Antioxidant Activity of Triphala
It exerts cytotoxic effect on cancer cells. This effect could be attributed to gallic acid present
in triphala. Triphala extract exhibited antimutagenic activity on Ames histidine reversion
assay. By increasing the antioxidant status of animals, the incidence of tumor formation is
reduced. In addition, it also has a radioprotective effect. The polyphenols in triphala help in
converting reactive oxygen free radicals to nonreactive products. It increases the nonspecific stress-tolerating capacity [37–41].
Studies have reported that Emblica officinalis fruit also has antioxidant and anti-aging
properties [1–3, 5]. Terminalia bellerica is the most active antioxidant followed by Emblica
officinalis and Terminalia chebula [2].
19.5.2
Wound Healing Properties
Triphala promotes wound healing by exerting antibacterial activity against wound pathogens. In addition, epigallocatechin gallate contributes to faster wound closure and improved
tissue regeneration [41]. Terminalia chebula leaves extract, when applied on wounds in rats,
caused wounds to heal faster mainly by improving rates of contraction and reduction in
epithelialization period.
19.5.3
Antibacterial Activity of Triphala
It exerts antibacterial activity against a wide range of bacteria including both gram-positive
and gram-negative species. In addition to its activity on dental pathogens, it has antimicrobial activity on Klebsiella pneumonia, Shigella sonnei, Staphylococcus aureus, Vibrio cholerae,
E. coli, Pseudomonas [41]. Fruits of Terminalia chebula, when used alone, also exhibited
anti-bacterial, anti-fungal, and anti-viral properties [1].
19.5.4
Anti-Diabetic Effect
Rat experiments have demonstrated a decrease in blood sugar level on administration of
triphala extract [41].
19.5.5
Anti-Inflammatory, Analgesic, and Antipyretic Effect
Gallic acid present in triphala is a cyclooxygenase-2 (COX-2) inhibitor. In animal experiments, triphala, in combination with other herbs, was found to have analgesic and antipyretic effects [41]. The Emblica officinalis fruit has application as an antipyretic, analgesic,
cytoprotective, anti-tussive, and gastroprotective agent [1–3, 5]. The fruit of Terminalia
308 Natural Oral Care in Dental Therapy
chebula has shown anti-mutagenic/anti-carcinogenic, cytoprotective, and radioprotective
activity [1].
Due to its anti-inflammatory, antioxidant, and antineoplastic activity, Triphala may play
a role in the treatment of tobacco-induced oral mucosal lesions.
19.5.6
Immunomodulatory Effect
The flavonoids, alkaloids, glycosides, saponins, and phenolic compounds present in triphala
are responsible for its immunomodulatory effect [41]. The fruits of Emblica officinalis and
Terminalia chebula have an immune-modulatory effect [1–3, 5].
The components of triphala exhibit the following activities individually:
Terminalia chebula exhibits anti-anaphylactic and hypolipidemia/hypercholesterolemia
activity. It also helps in improving gastro-intestinal motility.
Terminalia bellerica possesses bronchodilator, cardioprotective, hepatoprotective, hypoglycemic, and hypotensive properties [1, 2].
Emblica officinalis has anti-pyretic, anti-tussive, and gastroprotective properties
[1–3, 5].
19.6 Public Health Importance
Triphala has exhibited a range of protective activities on oral health. Few studies have
reported it to be as effective as the conventional drugs. Future research should be directed
toward assessing the effect of the combination of triphala with synthetic drugs on oral
health.
19.7 Formulation Using Triphala
Triphala tablet, Triphala churna (Dabur India Ltd, New Delhi, India), Triphala capsule
(Himalaya Drug Company, Bangalore, India), Triphala mouth rinse, Salz Triphala toothpaste (Lion Corporation, Thailand), and Himalaya toothpaste with triphala are the formulations of Triphala.
19.8 Conclusion
Triphala is an herb with a wide spectrum of beneficial effects on human health. It has
been in use since time immemorial. The emerging scientific evidence supporting its
traditional use and demonstration of newer pharmacologic activities could go a long
way in triphala forming an adjuvant mainstream drug in dentistry as well as in general
medicine.
Triphala and Oral Health 309
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310 Natural Oral Care in Dental Therapy
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Triphala and Oral Health 311
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20
Azadirachta indica (Neem): An Ancient Indian
Boon to the Contemporary World of Dentistry
Sri Chandana Tanguturi*, Sumanth Gunupati and Sreenivas Nagarakanti
Department of Periodontology, Narayana Dental College and Hospital, Nellore, Andhra Pradesh, India
Abstract
Known as the “Miracle tree” and “Arishta” (Sanskrit for Sickness reliever), Azadirachta indica
(Neem), belonging to the Meliaceae family, from prehistoric Indian subcontinent, for its multitudinous medicinal properties. With globalization, it has gained even more recognition and acceptance
worldwide, especially for having no side effects or complications. By virtue of its natural antibacterial
and antimicrobial properties, it has diverse applications in dentistry, as most of the oral diseases
are microbe induced. With active ingredients such as, Nimbidin, Azadirachtin, and Nimbinin that
can eliminate oral aerobic and anaerobic bacteria, Neem is extensively used as a root canal irrigant,
mouthwash for treatment of gingivitis, and toothpaste with good anti-cariogenic properties, among
numerous other oral hygiene products. Though there are many scientific studies explaining Neem’s
diverse applications in dentistry, literature that reviews them has been scarce. The aim of this chapter
is to review Neem’s phytochemistry, mechanism of action, use of the tree’s various parts in dentistry,
their chemical constituents, and biological effects.
Keywords: Anti-inflammatory agent, Azadirachta, oral health, periodontal disease,
root canal irrigant
20.1 Introduction
Nowadays, the use of medicinal plants in the treatment of many diseases has gained significant importance, as people have become ever more cognizant of the side effects of synthetic
drugs and, hence, are fascinated by the use of plant-based medications. The gaining popularity and demand for herbal medicines may lead to unmethodical and unscientific collection, misidentification, and adulteration without any standards for quality of the material,
especially in developing countries. Ahmad et al. (2010) [1] noticed that in the markets of
India and Pakistan, oftenly different products are being sold under the same trade name,
which is dangerous. Hence, there is an immense need to describe the drugs in a systematic
and scientific manner, and collect, process, extract, isolate, characterize, and identify its
chemical compounds. Scientific methodologies should be developed to maintain standards
*Corresponding author: drchandana87@gmail.com
Durgesh Nandini Chauhan, Prabhu Raj Singh, Kamal Shah, and Nagendra Singh Chauhan (eds.)
Natural Oral Care in Dental Therapy, (313–328) © 2020 Scrivener Publishing LLC
313
314 Natural Oral Care in Dental Therapy
and quality assurance of these herbal drugs. To help this cause, the authors have compiled
and evaluated literature on Azadirachta indica (Neem), one of the most widely used therapeutic plants. Neem is native to the Indian subcontinent and grows well in tropical and
subtropical regions. Owing to its innumerable medicinal benefits, Neem is appropriately
called “Divine Tree” [2–5]. Mature trees grow up to 7–20m high and may live for more than
200 years [6]. Azadirachta indica is a Latin term that denotes “Azad” for “free”, “dirakht” for
“tree”, and “I” for “Hind” meaning belonging to Indian origin. In Sanskrit language, “Neem”
is called “arista” meaning “complete & imperishable” [7].
20.2 Vital Bioactive Compounds of Neem
Although numerous compounds (approximately 135) [8] have been extracted from different parts of Neem, only a few compounds’ biological activity was studied extensively, which
are discussed in this chapter in detail, along with their medical and dental applications.
The following are some of the biologically active compounds of neem with therapeutic role:
20.2.1
Nimbidin
Nimbidin, the major bitter principle extracted from the oil of neem seed kernels, possess
several therapeutic properties. Several other bioactive compounds, which are tetranortriterpenoids like nimbin, nimbinin, nimbidinin, nimbolide, and nimbidic acid, have been
isolated from nimbidin [9, 10].
• Anti-inflammatory activity:
In an animal study on rats, Nimbidin and Sodium Nimbidate showed significant anti-inflammatory activity [11, 12].
Nimbidin has the ability to suppress the macrophage and neutrophil functions and, thus, has anti-inflammatory action. Nimbidin has the ability to
inhibit nitric oxide (NO) and prostaglandin E2 (PGE2) production in macrophages following in vitro exposure [13].
• Antipyretic activity:
A study conducted by David S.N (1996) [14] confirms the antipyretic activity
of Nimbidin.
• Hypoglycemic effect:
Oral administration of Nimbidin in fasting rabbits showed a significant difference [15].
• Antiulcer effect:
Nimbidin prevents gastric lesions as well as duodenal ulcers [16, 17] and suppresses gastric acid output [18].
• Antibacterial and antifungal effect [19]:
It is bactericidal as it has the ability to inhibit the growth of Mycobacterium
tuberculosis, and it is a potent antifungal as it can inhibit the growth of Tinea
rubrum.
Role of Azadiraciita indica in Dentistry 315
20.2.2
Azadirachtin
It belongs to the limonoid group and is a secondary metabolite present in neem seeds. Antiinflammatory activity:
Azadirachtin possesses antiradical scavenging activity and reductive potential [20].
• Antimalarial activity:
It also inhibits the development of malarial parasites and a very good antimalarial agent [21].
20.2.3
Nimbolide
Nimbolide is a limonoid tetranortriterpenoid with an α,β-unsaturated ketone system and
a δ-lactone ring.
• Anti-inflammatory activity:
It possesses antiradical scavenging activity and reductive potential [20]
• Anti-bacterial and anti-malarial effect:
The growth of Plasmodium falciparum and Streptococcus aureus and coagulase [22, 23].
20.2.4
Gedunin
It is an active component extracted from neem seed oil.
• Anti-neoplastic activity:
Gedunin can inhibit the proliferation of cancer cells including those of the
prostate, ovary, and colon [24, 25].
• Antimalarial and anti-fungal activity [26, 27]
20.2.5
Mahmoodin
It is a deoxy-gedunin isolated from neem seed oil.
• Antibacterial activity:
It inhibits growth of various Gram-positive and Gram-negative organisms [28].
20.2.6
Tannins
• Anti-inflammatory activity
During inflammation, Tannins have the ability to inhibit oxidative burst of
PMN [22].
20.2.7
Diterpenoids
The three tricyclic diterpenoids are margolone, margolonone, and isomargolonone [29, 30].
316 Natural Oral Care in Dental Therapy
• Antibacterial activity:
They are active against Staphylococcus, Klebsiella, and Serratia species.
20.3 How to Distinguish Azadirachta Indica (Neem) from its
Common Adulterant Melia Azedarach
Considering the high probability of accidental or deliberate misidentification of the
neem tree, there should be some standards set for quality assurance. In a study conducted by Shazia sultana et al. (2011) [31], Azadirachta indica was distinguished
from its adulterant Melia azedarach, based on morpho-palynological and foliar epidermal
anatomy. Using pharmacognostic tests, the powdered drug can be distinguished based on
solubility and fluorescence analysis. Solvents like HNO3 and C6H6 are recommended as a
good test for authenticating the herbal drug Neem.
20.4 Therapeutic Applications of Neem
Azadirachta indica (Neem) possesses plethora of therapeutic properties because of its rich
source of its bioactive component, as shown in Figure 20.1. Various parts of the neem tree
* Regulation of proinflammatory enzyme activities
including cyclooxygenase (COS), and lipoxygenase (LOX)
enzyme
Neem
Azadiracta Indica
* Suppress the macrophage and neutrophil functions.
Anti-Inflammatory
Anti-Oxidant
* Inhibits nitric oxide (NO) and prostaglandin E2 (PGE2)
production
Free radical
scavenging
activity
* Activates apoptosis, suppression of NF-κB signaling, and
cyclooxygenase pathway
Anti-Cancerous
Anti-Bacterial
Disrupts the integrity
of the bacterial cell
membrane leading to
disturbance in
osmotic pressure that
ultimately leads to
cell death
Anti-Viral
Anti-Fungal
* Activate the tumour suppressor genes and inactivate the
activity of genes involved in the cancer development and
progression such as VEGF, NF-κB, and PI3K/Akt
• Interferes at the early events of
virus replication
* Inhibits cytoadhesion.
• Increase superficial
hydrophobicity on cells
* Inhibits ergosterol biosynthesis.
Wound-Healing
Increased inflammatory response and
neovascularization.
Figure 20.1 Therapeutic activities of bioactive components of neem and their mechanism of action.
Role of Azadiraciita indica in Dentistry 317
are used for the treatment of various ailments like infections, fever, respiratory disorders,
leprosy, intestinal helminthiasis, constipation, skin, and oral diseases.
20.4.1
Neem as an Anti-Inflammatory, Analgesic Agent
Most of the systemic diseases are inflammatory. Though there are many synthetic antiinflammatory drugs, many of them have serious side effects. Usage of herbal medicines is
in practice for treating inflammatory conditions. Many natural anti-inflammatory drugs
are available in the market, among them, Neem is considered to be the best, owing to its
therapeutic benefits.
Regulation of proinflammatory enzyme activities makes Neem a potent anti-inflammatory
agent [32]. Nimbidin, isolated from seed oil, has the ability to suppress the macrophage
and neutrophil functions. It also inhibits nitric oxide (NO) and prostaglandin E2 (PGE2)
production in macrophages following in vitro exposure [13].
According to a study conducted by A. S. M. Mosaddek et al. (2008) [33], the neem leaf
extract showed significant anti-inflammatory effect, but it is less efficacious than that of
dexamethasone. A study conducted on albino rats showed that neem seed oil showed significant dose-dependent analgesic activity [34]. In a study conducted by K. Ilango et al.
(2013) [35] showed significant antinociceptive and anti-inflammatory activities.
20.4.2
Antioxidant Activity
Antioxidants deactivate free radicals often before they attack targets in biological cells and
play a role in the activation of antioxidative enzyme control damage caused by free radicals/
reactive oxygen species [36]. Neem has free radical scavenging properties due to a rich
source of antioxidants such as Azadirachtin and nimbolide [20]. According to a study conducted by A. K. Ghimeray et al. (2009) [37] on leaf and bark extracts of neem grown in the
foothills of Nepal, they showed significant antioxidant properties.
20.4.3
Anticancerous Activity
Cancer is one of the life-threatening diseases that have multifactorial etiology. The known
fact is that drugs used for treating cancer cause after effects. Neem contains flavonoids and
various other components that play a key role in the inhibition of cancer development and
progression.
A tumor suppressor gene, p53 plays an important role in the inhibition of abnormal cell proliferation and thus preventing the progression of cancer. A study conducted by Arumugam A et al. (2014) [38] showed that ethanolic fraction of neem
leaf (EFNL) treatment effectively upregulated the proapoptotic genes and proteins
including p53.
In many tumors, pTEN in activation is noted. A study confirmed that the ethanolic fraction of neem leaf treatment significantly increased the expression of pTEN,
which could inhibit mammary tumorigenesis through its inhibitory effect on Akt [38].
Nimbolide acts as a potent anticancer agent by inducing apoptosis and inhibiting cell
proliferation [39].
318 Natural Oral Care in Dental Therapy
20.4.4
Antimicrobial Activity
Drug resistance is a side effect of antimicrobial drugs and is a serious issue globally. Usage
of a natural antimicrobial agent like Neem is a viable solution.
20.4.4.1
Antibacterial Activity
Oil from the leaves, seeds, and bark possesses a wide spectrum of antibacterial action
against Gram-negative and Gram-positive microorganisms [40]. According to a study conducted by M. B. Yerima et al. (2012) [41], the bark extracts showed antibacterial activity at
all the concentrations.
20.4.4.2
Antiviral Activity
Neem leaf extracts have shown virucidal activity against B-4 of coxsackievirus [42]. Neem
bark (NBE) extract significantly blocked the entry of HSV-1 into cells from 50- to 100-μg/mL
concentrations [41].
20.4.4.3
Antifungal Activity
A study by Mondali NK et al. (2009) [43] confirmed that the growth of fungal species
Aspergillus and Rhizopus was inhibited by both alcoholic and neem leaf water extracts. A
study by Shrivastava DK (2014) [44] showed inhibition of Aspergillus flavus, Alternaria
solani, and Cladosporium.
According to study conducted by Raja Ratna Reddy Y et al. (2013) [45], the leaf extract
exhibited strong antimicrobial activity against bacteria and fungi, namely, Pseudomonas
aeruginosa, Proteus mirabilis, Enterococcus faecalis, Staphylococcus aureus, Aspergillus fumigates, and Candida albicans at all the concentrations tested.
20.4.4.4
Antimalarial Activity
Udeinya JI et al. (2008) [46] concluded in a study that the number of parasites in the control
crops was less than 50% when treated with crude acetone/water (50/50) leaf extract (IRAB).
20.4.5
Wound Healing Effect
A study conducted by Barua CC et al. (2010) [47] showed the significance of the wound
healing activity of neem leaf extracts in both excision and incision wound models. In addition, the tensile strength of healing tissue of both treatment groups of plants was found to
be significantly higher in incision wound compared to the control group [48].
20.5
Applications of Neem in Dentistry
Nowadays, oral diseases are of major public health concern throughout the world. Based
on scientific studies, there is a high correlation between poor oral hygiene status, dental
plaque, and severity of dental problems. Therefore, the treatment of localized oral infections
Role of Azadiraciita indica in Dentistry 319
has been prioritized in dental therapy. Owing to the side effects of synthetic drugs, usage of
natural herbs is mushrooming.
The dental benefits of Neem (Azadirachta indica) are described in detail below:
20.5.1
Neem in Treatment of Periodontal Diseases
Periodontitis is an immunoinflammatory disease where there is overproduction of free radicals, in which antioxidants in our body will be unable to counteract, leading to periodontal tissue destruction. Eventually, antioxidant supplements must be used to help regulate
overproduced free radicals in periodontal tissues. Hence, to treat such a complex disease, a
drug with antimicrobial, anti-inflammatory, and antioxidant properties should be chosen.
Though there are several commercially available drugs with such properties, they alter the
oral microbiota and cause side effects like vomiting, diarrhea, bacterial resistance hypersensitivity, immunosuppressive and allergic reactions, and tooth staining. Hence, natural
phytochemicals isolated from plants are considered as good alternatives in treating oral
diseases and can be used as adjuvants for mechanical procedures.
According to a recently published systematic review by Dhingra K et al. (2016) [49], the
neem mouth rinse was as efficacious as an anti plaque and anti gingivitis agent when used
as an adjunct to tooth brushing in gingivitis patients. In a study conducted by Abhishek KN
et al. (2015) [50], the usage of neem-containing toothpaste showed a significant difference
in plaque index and gingival index, and it was thereby suggested that it could be used as an
adjunct for maintenance of oral hygiene.
In a study performed by Sharma R et al. (2014) [51] on children, the authors concluded
that when neem, mango, and chlorhexidine mouthwashes were compared, chlorhexidine
and neem possess equivalent efficacy in reducing plaque, while chlorhexidine has superior antigingivitis properties. A double-blind, randomized, controlled trial confirmed that
A. indica-based mouth rinse is equally efficacious with fewer side effects compared to chlorhexidine [52].
In conventional local drug delivery, herbal products can eliminate certain shortcomings in
using synthetic drugs. In a clinico-microbiological study of 10% neem oil chip as a local drug
delivery system, clinical parameters showed statistical improvement, and P. gingivalis strain
load was significantly reduced in the periodontal pockets treated with the neem chip sites [53].
In a comparative study, the authors found that chlorhexidine gluconate gel and neem extract
gel are clinically equally effective [54]. Neem extract has shown to reduce matrix metalloproteinases (MMP-2 & MMP-9) levels, though not more than that of doxycycline [55].
The above-mentioned scientific studies strongly put the onus on the role of Azadirachta
indica-based herbal preparations (mouthrinse, chips, gel, and toothpaste) as effective antiplaque and anti-inflammatory agents. Being of herbal origin, A. indica can be used as a safe
alternative to the gold standard chemical plaque-controlling agent, chlorhexidine gluconate. However, multicenter studies with larger sample sizes and long terms are to be conducted to establish its utility as an adjunct to periodontal therapies.
20.5.2
Role of Neem in Endodontics
The endodontic treatment is said to be completed when there is complete elimination
of microbes in the root canals, viz. maximum disinfection. The most commonly found
320 Natural Oral Care in Dental Therapy
microorganisms in failed/infected root canals are Enterococcus faecalis and Candida albicans. Being a natural product with less side effects, it is preferable to use neem as an endodontic irrigant. While, more scientific studies need be conducted to emphasize its role in
endodontics, we have reviewed the following studies showing the efficacy of Neem as a root
canal disinfecting agent.
• Chandrappa et al. (2015) [56] found that when neem extract, tulsi extract,
and chlorhexidine are used as irrigants, all of them showed significant antibacterial efficiency against E. faecalis.
• Babaji et al. (2016) [57] concluded that neem, M. citrifolia, and Aloe Vera are
efficient root canal irrigating solutions.
• Studies conducted by Sundaram et al. (2016) [58] and Prasad et al. (2016)
[59] also proved the antibacterial efficacy of herbal irrigants with conventional irrigants. Dutta et al. (2014) [60] concluded that neem had good
anti-microbial efficacy.
20.5.3
Potent Role of Neem in Preventive Dentistry
Preventive dentistry saves a lot of time, money, and pain caused by dental problems. Using
natural and efficient therapeutic drugs like neem extracts in preventive dentistry makes
even more sense as we will also be avoiding any side effects.
20.5.3.1
Application in Dental Erosion Therapy
Dental erosion is the wearing of dental hard tissues by means of acid etch, which is nonbacterial in origin that leads to its demineralization and dissolution. Sales Peres AC et al.
(2013) [61] concluded that application of a Neem–fluoride gel combination is more efficient
than the sole application of Neem gel in the prevention of dental erosion Therefore, these
compounds might be considered to act synergistically or additively with respect to inhibition of demineralization.
20.5.3.2
Anti-Microbial Activity
Based on the above-discussed literature [41–46, 49–60] we can excogitate that neem is an
efficient and potent antimicrobial with negligible side effects. There is a plethora of its antibacterial applications in medicine and dentistry. It is successfully used as antiplaque and
anti-gingivitis, which are the culprits for gingival and periodontal diseases.
20.5.3.3
Anticaries Activity of Neem
The Neem extract has been found to be active against the caries-causing organisms with the
capability of not only inhibiting their growth but also reversing incipient/initial caries. The
following studies prove that neem extracts possess anticaries effect, thus, is useful in preventive dentistry. According to Vanka A et al. (2001) [62] the Azadirachta indica mouthwash
has the ability to inhibit Streptococcus mutans and reverse incipient carious lesions. In an
in vitro study conducted by Prashant GM et al. (2007) [63], the authors analyzed the effect
Role of Azadiraciita indica in Dentistry 321
of mango and neem extract on four dental caries-causing microorganisms, Streptococcus
mutans, Streptococcus salivarius, Streptococcus mitis, and Streptococcus sanguis. Neem
extract produced a maximum zone of inhibition on S. mutans at a 50% concentration.
20.5.3.4
Anti-Candidiasis Property
Candida species are opportunistic fungal infections that usually affect immune-compromised, immunosuppressed patients causing a wide range of infections like oral thrush,
intestinal candidiasis, vaginal thrush, etc. Owing to the side effects caused by the standard
local and systemic treatments, it is safe to opt for herbal remedies. Polaquini SR et al. (2007)
[64] have shown that A. indica components have hydrophobic and anti-adhesive action
against dental biofilm.
20.5.3.5
Anti-Cancer Property
Flavonoids play a key role in the inhibition of cancer development and progression. The
chemopreventive effects of neem in the oral mucosa are by modulating lipid peroxidation,
antioxidants, and detoxification systems [65]. Harish Kumar, G et al. (2009) [66] found
that nimbolide is a more potent antiproliferative and apoptosis-inducing agent. Ethanolic
neem leaf extract (ENLE) exerted its anticancer properties by inhibiting cell proliferation
and inducing differentiation and apoptosis [67]. The antioxidant properties of neem leaf
fractions may be responsible for modulating key hallmark capabilities of cancer cells such
as cell proliferation, angiogenesis, and apoptosis [68].
It is evident from the above discussion that studies are conducted only on animals till
date on oral carcinomas, while preclinical and clinical studies with superior quality are warranted to establish the utility of neem in the treatment and prevention of oral carcinomas.
20.6
Literature Supporting the Use of Neem in Dentistry
In a study conducted by Joy Sinha D et al. (2017) [69] neem is as effective as chlorhexidine or
sodium hypochlorite in inhibiting the growth of E. faecalis. RC Patil et al. (2017) [70] confirmed
the antibacterial activity of Neem against Escherichia coli, Staphylococcus aureus, Klebsiella
pneumonia, Enterobacter aerogenes, Pseudomonas aeruginosa, Salmonella typhimurium,
Salmonella typhi, Staphylococcus epidermidis, and Proteus vulgaris. When antimicrobial activity of Azadirachta indica (AI), Triphala, Curcuma longa, and Morinda citrifolia (MC) against
E. faecalis were compared, Propolis and AI showed significant antimicrobial activity [71].
Neem extract is an effective antifungal against C. albicans and is comparable to 3%
NaOCl [72]. When antimicrobial efficiency of Neem leaf extract, 2% chlorhexidine, 3%
sodium hypochlorite were assessed, neem leaf extract showed comparable zones of inhibition with that of chlorhexidine and sodium hypochlorite, and thus, it can be used as an
intracanal medication [73]. The authors concluded that neem mouthwash can be used as an
alternative to chlorhexidine mouthwash [74]. When the antimicrobial effects of the aqueous extracts of neem, miswak, mango, and banyan chewing sticks were compared against
Streptococcus mutans and Lactobacillus acidophilus, neem showed the most antimicrobial
322 Natural Oral Care in Dental Therapy
activity against S. mutans [75]. When efficacy of Neem, Tulsi, and Guduchi extracts were
compared as intracanal medicaments, Neem was found to be the most potent medicament
followed by Tulsi and Guduchi [76]. A recent study conducted by Hamid SK et al. (2019)
[76] suggested that adding neem powder to acrylic resin denture base materials reduces the
adhesion of C. albicans and hence could be useful in preventing denture stomatitis.
20.7
Toxicity and Safety
In the United States of America, 8% of hospital admissions are due to adverse or side effects
of synthetic drugs [77]. The most important advantage of herbal medicine is the negligible
side effects and is relatively less expensive than synthetic drugs. Though neem has multitudinous medicinal properties, its indiscriminate use, particularly when taken in overdoses,
may cause undesirable side effects. Traditional ayurvedic practitioners recommend against
the use of neem in people with obvious wasting or fatigue, infants, children, pregnant or
nursing women, patients with impaired liver or kidney function. Excess doses of seed or
seed supplements may be toxic [78].
Although numerous animal studies are conducted on the safety of various parts of neem,
there are no quality-controlled studies on humans evaluating its safety. There is compelling
necessity for human studies on neem extracts, so that it can be more generously utilized at
granular and general levels in dental hygiene and therapy.
20.8
Contamination and Adulteration
There is a good possibility that herbal products are contaminated or even deliberately adulterated. Such failures in quality control are rare, but when they occur, they can be serious effects. These types of safety hazards are seen more frequently in herbal supplements
imported from India, China, or other countries where quality control procedures are less
stringent than in the United States (Reports from University of Minnesota, 2007–2011).
Safety of most herbal products is compromised due to lack of suitable quality controls,
inadequate labeling, and the absence of appropriate patient information [79].
20.9
Drug Interactions
Owing to the assumed safety of herbal products, it is a common practice to often combine
these products with synthetic drugs with resultant herb–drug interactions. Usually, most
patients do not disclose this practice of co-administration to their health care providers,
and thus, many of the health care providers being less informed of herbal–drug interactions
may cause serious adverse effects. Most times, the potential risks of drug–herbal interaction, even when known, are often ignored or underestimated. One should be cautious while
prescribing neem along with anti-diabetic drugs as neem has a hypoglycemic effect [15].
Taking neem along with diabetes medications might further lower the blood sugar levels
more. Because of the immunostimulant property of neem [80], it is not advisable to use it
in patients taking immunosuppressants.
Role of Azadiraciita indica in Dentistry 323
20.10 Neem’s Prospects in Dentistry
From literature reviewed so far, we can establish the current usage of neem in dentistry.
Various Neem products that can be used or are being used for dental hygiene and therapy
are:
1. Neem mouth rinse is a strong and effective antiplaque agent and can be used
as an adjunct to tooth brushing in gingivitis patients with equivalent antiplaque efficacy to 0.2% Chlorhexidine mouthwash, but less effective antigingivitis property.
2. Neem chewing sticks as an adjuvant to oral brushing.
3. Neem gel is more effective than mouthwash.
4. Neem-based toothpastes are effective in reducing plaque and gingival index.
5. Neem chip (10%) can be used as a local drug delivery adjunctive to mechanical therapy in chronic periodontitis patients.
6. The antimicrobial property of Neem makes it a potent root canal irrigant.
7. Phytochemicals of A. indica have been shown to arrest tumor cell growth and
proliferation, making it a drug of choice with minimal side effects for oral
carcinomas.
20.11 Action Points and Recommendations for Health Care
Professionals
Healthcare Professionals, such as physicians, nurses, and pharmacists, often have little
knowledge of properties of herbal medicines, their safety, mechanism of action, and interactions with synthetic drugs. Most patients use herbal products but do not reveal to the
doctor about the herbal drugs as they assume that “Herbal” or “natural” means safe and
benign in interaction with any other drug. Education of healthcare professionals is vital to
prevent misuse of herbal medicines. It is mandatory to follow drug regulatory policies for
herbal medicines to ensure safety, quality, and efficacy. It is well known that Neem was used
since ages with minimal side effects. In the light of the above-discussed facts, Neem was
shown with multitudinous medicinal applications making it a very useful drug for treating
many ailments, especially oral. Hence, all the physicians, dentists, and pharmacists should
focus and work intensively on developing, promoting, and including Neem extracts in their
daily practice and, at the same time, considering its safety aspect and contraindications.
During this process, they must take interest in procuring information about neem from
physicians of Ayurveda that will make the process easy.
20.12 Conclusion
Neem is considered a safe alternative and adjuvant to conventional and synthetic drugs
that are being used in dentistry. Although many studies have shown promising results
on the use of Neem, most of them are conducted on animals. Multicentre studies with
324 Natural Oral Care in Dental Therapy
larger sample sizes and long terms are to be conducted to further establish and commercialize its role in dentistry. Regulatory policies are to be standardized in identification, extraction, isolation, and production of various neem formulations. When taken
in overdoses or incorrect combination with other synthetic drugs, Neem products can
cause some side effects. It is, therefore, advisable that these products are to be prescribed
by qualified medical practitioners and dentists. Health care professionals would need to
proactively motivate patients to help inculcate more natural products into their lifestyle
and that Neem will do good to head their list. Publicizing Neem’s use cases on global
healthcare platforms will help establish India’s contribution to the medical industry in
general and Dentistry in particular.
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Med., 9, 94, 2011.
80. Upadhyay, S.N., Dhawan, S., Garg, S., Talwar, G.P., Immunomodulatory Effects of Neem
(Azadirachta indica) Oil. Int. J. Immunopharmacol., 14, 1187, 1992.
21
Ginger in Oral Care
Aditya Ganeshpurkar*, Abhilasha Thakur and Anupam Jaiswal
Shri Ram Institute of Technology-Pharmacy, Jabalpur, Madhya Pradesh, India
Abstract
Mankind has been using medicinal plants for the treatment of diseases from prehistoric era. The
roots, leaves, stems, flowers, seeds, and tubers of the plants are utilized for isolation of various bioactive constituents. Ginger is an important medicinal herb, the medicinal benefits of which are mentioned in Ayurveda. Ginger is extensively used for its flavor. Various cuisines use ginger for its aroma.
With the view of its biological and pharmacological effects, gingerols, and shogoals are among the
few of its constituents responsible for its therapeutic effects. Ginger is scientifically validated for oral
care. Ginger extracts are known to possess antimicrobial, antifungal, oral anticancer, anti-nausea,
anti-carries, and antiplaque properties. Ginger is known to harden the teeth due to indirect remineralization property. Thus, overall, the health benefits of ginger in oral care make it useful for
treatment of various oral disorders.
Keywords: Ginger, antimicrobial, antifungal, oral anticancer, anti-nausea, anti-carries, antiplaque
21.1 Introduction
The use of herbs for the treatment of disease dates back to prehistoric era. The use of complement and alternative medicine to cure diseases is followed by many parts of the globe.
These therapies are more economical and are widely accepted. The medicinal plants have
immunomodulatory [1–4], analgesic [5, 6], anabolic [7], antitumor [8, 9], and antimicrobial
[8, 10] bioactives. The extensive phytochemical analysis has provided an in-depth knowledge about structural and functional properties of plant-derived bioactives. Ginger comprises the dried rhizome of Zingiber officinale Roscoe (Family Zingiberaceae) [11]. Ginger
is one of the widely eaten dietary condiments worldwide. Ginger is spicy and aromatic. The
aromatic flavor is predisposed due to the presence of gingerols in it. The use of ginger in
the Asian subcontinent dates back 5000 years ago. Indian and Chinese food and medicine
employ ginger as one of the key herbs for aroma and health. India is the second largest cultivator of ginger with an annual production of 385,000 tons after China. In India, Kerala,
Orissa, Arunachal Pradesh, Karnataka, Sikkim, West Bengal, and Madhya Pradesh are the
major ginger-producing states.
*Corresponding author: adityaganeshpurkar@gmail.com
Durgesh Nandini Chauhan, Prabhu Raj Singh, Kamal Shah, and Nagendra Singh Chauhan (eds.)
Natural Oral Care in Dental Therapy, (329–344) © 2020 Scrivener Publishing LLC
329
330 Natural Oral Care in Dental Therapy
21.2 Description
It is a perennial herb with branched rhizome Table 21.1. The shoot grows up to 1.50 m in
height. The leaves are lanceolate with an alternate arrangement. The stems of the flowers
are shorter than the stems of the leaves. The flower has a superior tubular calyx. There is
an orange yellow corolla differentiated above into three linear oblong, blunt lobes, with six
staminodes in two rows. The fruit is a capsule with small arillate seeds [12, 13].
21.3 Macroscopic Characteristics
Table 21.1 Macroscopic characteristics of ginger.
Character
Inference
Color
Brown to pale yellow
Odor
Characteristic aromatic
Taste
Aromatic, Pungent
Size
3–16 cm long, 3–4 cm wide, up to 2 cm thick
Shape
Horizontal, laterally flattened, irregularly branching pieces
21.4 Pharmacognostic Standards
Table 21.2 Pharmacognostic standards of ginger.
Standards
Value
Reference
Foreign organic matter
Not more than 2.0%
[11]
Total ash
Not more than 6.0%
[14]
Acid-insoluble ash
Not more than 2.0%
[15]
Water-soluble extractive
Not less than 10%
[14]
Alcohol-soluble extractive
Not less than 4.5%
[14]
Heavy metals
Lead
Cadmium
10 mg/kg
3 mg/kg
[16]
Ginger in Oral Care 331
Table 21.3 Proximate composition of ginger.
Constituents [18]
Percent
Protein
5.8
Crude fiber
5.4
Fat
0.9
Ash
3.5
β-carotene
0.81
Ascorbic acid
3.8
Calcium
69.2
Iron
1.8
Copper
0.75
21.5 Nutrient Composition
Ginger is used as an integral seasoning in various cuisines. Due to presence of essential oils,
it has a characteristic aroma. It is used to impart flavor to tea, coffee, decoctions, confectionery, soft drinks, beverages, and many other dishes. Ginger is also used in pickles. Ginger
can be desiccated to make ginger powder. The “so formed” ginger powder is stable for a
long period of time compared to fresh ginger. The presence of a variety of constituents like
6-shogoals, 6-gingerol, bisabolene, and zingiberene imparts a pungent and aromatic taste
to it [17]. Ginger can be regarded as a good source of mineral elements, essential amino
acids, and nutrients, Table 21.2 and Table 21.3. The general nutrient composition of ginger
is summarized in Table 21.3.
21.6 Pharmacological and Medicinal Effects
21.6.1
Oral Analgesic Effect
A validated clinical study has been performed on ginger to evaluate its anti-inflammatory
and analgesic property over postsurgical pain. In this study, 60 patients undergoing mandibular third molar removal participated in the study. In this study, patient volunteers were
divided randomly into three groups. The first group received the capsule of ginger (rhizome) (500 mg). The second group received ibuprofen (400 mg), whereas the third group
received placebo. In this study, the cardinal parameters like amount of mouth opening,
pain, cheek swelling, and serum high-sensitivity C-reactive protein (hsCRP) were taken
into consideration.
On day 5, the maximal mouth opening offered due to ibuprofen treatment was 36.3 ± 11
where administration of ginger demonstrated a maximum mouth opening of 35.3 ± 10.
There was a noteworthy decrement in cheek swelling due to administration of ginger capsule (32.6 ± 3.7) compared to that of the ibuprofen treatment (34.7 ± 4.4). Median pain
332 Natural Oral Care in Dental Therapy
score after 12 h of ginger capsule administration was 24.6 ± 6.3 mm. There was no observable abnormal wound bleeding. There was insignificant difference in C-reactive protein levels. The outcomes of the study revealed the significant effectiveness of ginger in controlling
postoperative dental pain [19].
21.6.2
Antimicrobial Effect
Streptococcus mutans is found in the oral cavity and forms a biofilm on the surface of the
teeth. The formation of dental plaque prevents permeation of antimicrobial agents producing resistance to antibiotics [20]. In a study, the antimicrobial effect of ginger against
Streptococcus mutans was evaluated. The minimum inhibitory concentration and minimum bactericidal concentration was found to be 256 μg/ml. The crude ginger extract
revealed antibacterial activity with more than 5-log CFU/ml, whereas methanolic fraction
showed a decrement of 4-log CFU/ ml, Figure 21.1. There was a noteworthy anti-adherence activity, which was due to a decrease in sucrose-dependent and sucrose-independent
adherence.
Crude ginger extract (128 µg/ ml) caused a decrement in sucrose-dependent and
sucrose-independent adherence by 78% and 73%, respectively. Methanolic fraction revealed
a decrease in sucrose-dependent and sucrose-independent adherence by 72% and 70%,
respectively. While accessing glucosyltransferases inhibitory activity, it was seen that crude
ginger extract caused a decrease in water soluble and insoluble glucans by 70%. Similar
inhibition was observed in the case of methanolic extract. The hydrophobicity index of
Streptococcus mutans was decreased by 75% and 71%, respectively.
There was an inhibition in biofilm formation during active accumulated phase, initial plateau accumulated phase, and plateau accumulated phase of growth of bacteria.
Initial pH drop was observed to be 7.25 to 6.83 in the case of crude extract, whereas
methanolic fraction caused a drop from 7.25 to 5.41. F-ATPase activity (0.25 MIC)
was decreased by 44% (methanolic fraction) and 53% (crude extract), respectively.
Crude extract decreased protein surface antigen by 50%, whereas methanolic fraction reduced surface antigen by 70%. Distortion of bacterial biofilm was seen, which
was evident from scanning electron microscopy and confocal scanning microscopy. Crude extract (85%) as well as methanolic fraction (68%) caused a decrement
in expression of brpA gene. Thus, all growth and propagation of Streptococcus mutans
was hampered by ginger extract [21]. Ginger extract was able to inhibit the growth of
Streptococcus mutans (30.0.0 ± 1.5 mm) and Lactobacillus acidophilus (21.0 ± 0.7 mm)
Figure 21.2, [22].
O
HO
OCH3
Ginger
Figure 21.1 Antimicrobial effect of Ginger.
Gingerol
OH
Ginger in Oral Care 333
Decrease in sucrose dependent
and sucrose independent
adherence
Glucosyltransferases inhibitory
activity
Decreased hydrophobicity
index of Streptococcus
mutans
Decreased biofilm formation
Decreased protein surface
antigen
Decreased expression of brpA
gene
Figure 21.2 Mechanism of antimicrobial effect of Ginger extract.
21.6.3
Anti-Carries Activity
Dental carries were developed in rats to study the anticariogenic effect of ginger extract. In
this study, rats were supplemented with 5% sucrose diet and inoculated with Streptococcus
mutans. Outcomes of the study revealed the beneficial effect of crude ginger extract in
preventing carries in the animals. The persistence of smooth surface was about 80% in
the ginger extract-treated group. Also, the incidence of formation was decreased [21].
Another independent study revealed a noteworthy inhibition (5 mm) over the microbes
found over the tooth [23]. The combination of ginger, cloves, and mint extracts revealed
a notable inhibition over caries forming bacteria, viz. Staphylococcus aureus (19 mm),
Granulicatellaadiacens (11 mm), Pseudomonas oryzihabitans (20 mm), Enterobacter cloacae (19 mm), Stenotrophomonas maltophilia (19 mm), and Pseudomonas putida (21 mm)
[24]. A study revealed the effectiveness of ginger as an auxillary chemical in association
with calcium hydroxide and chlorhexidine [25]. One of the active constituents of ginger,
zerumbone, showed a minimum inhibitory concentration of 250 μg/ml and a minimum
bactericidal concentration of 500 μg/mL against Streptococcus mutans and proved to be a
potential prophylactic anti-cariogenic agent [26].
21.6.4
Anti-Decay Effect
Tooth decay can be regarded as one of the most progressive diseases observed by infection
in the mouth followed by bad breath and weakness of the tooth. This is predisposed due to
accumulation of microbes on the surface of the enamel causing formation of a biofilm that
334 Natural Oral Care in Dental Therapy
causes erosion as well as decay of teeth. If this condition is left untreated, it can result in
injury to the pulp and loss of tooth [27]. Streptococcus sanguinis and Streptococcus mutans
are two bacteria that are known to cause damage to the teeth and gums. These microbes
biosynthesize the products, viz. levan and dextran, which are responsible for the formation
of dental carries. In severe tooth decay, these bacteria find their way toward bold stream
where they may cause endocarditis of the heart valves [28]. Ginger (drops) has been studied for its probable anti-decay effect. In a study, ginger (Arheumin drop, Iran) demonstrated a significant inhibition over the growth of Streptococcus sanguinis and Streptococcus
mutans. The MIC and MBC values of the extract (drops) were 0.02 and 0.04 mg/ml for
Streptococcus mutans and 0.3 and 0.6 mg/mL for Streptococcus sanguinis, respectively [29].
In another study, there was a decrement in bio-film formation during growth phase in
Streptococcus mutans. There was inhibition and decreased adherence toward synthesis and
tooth adherence of glucans. Similarly there was a significant decrement in sucrose-dependent
adherence as well as insoluble glucan synthesis. The results of the study also revealed a
downregulation of virulent gene [21]. Researchers suggested adding ginger (extract) into
mouthwashes to wield the inhibition over the growth over cariogenic bacteria, thus promoting inhibition over tooth decay. Similarly in another study, ginger, in association with
chlorhexidine and calcium hydroxide, demonstrated a notable inhibition over Enterococcus
faecalis and Escherichia coli. The levels of endotoxins were also decreased significantly [23].
21.6.5
Healing Effect in Root Canal Therapy
Root canal treatment is utilized for the treatment of infected pulp underlying the tooth.
It is followed by securing the tooth by a protective layer to prevent the tooth from future
microbial attack. Inert fillings like eugenol-based cements and gutta-percha are utilized to
fill the cavity. Sodium hypochlorite is a widely used irrigant in dental practice. It is an effective antimicrobial agent and also has the capability to dissolve tissues. The antimicrobial
effect of sodium hypochlorite increases with an increase in its concentration. A study was
designed to evaluate the antimicrobial and protective effect of sodium hypochlorite and
ginger extract microorganisms and endotoxins in endodontic treatment of infected root
canals. In this experiment, tooth was contaminated with bacteria and instrumentation for
root canal treatment was performed. After a period of 28 days, the content of root canal was
collected and analyzed for viable microorganisms. The results of studies indicated a synergy
between sodium hypochlorite and ginger extract, due to which, there was complete elimination (100%) of microorganisms and reduction of endotoxins (88%) [30]. Another study
aimed to determine the effect of propolis extract, ginger extract, calcium hydroxide, chlorhexidine gel, and their combinations against the growth of Candida albicans, Enterococcus
faecalis, and Escherichia coli. The antimicrobial effect was possibly due to the presence of
gingerol [31]. The outcomes of the present study revealed a synergistic decrease in microbial load and endotoxin [32].
21.6.6
Anti-Xerostomia Effect
Xerostomia is a condition observed by a decrease in salivary flow, which leads to difficulty in
swallowing, chewing, tasting, and chewing. Reduced salivary flow is also responsible for teeth
demineralization, decay of teeth, and sensitivity. The various reasons for xerostomia include
Ginger in Oral Care 335
rheumatoid arthritis, aging, head and neck cancer, Parkinson’s disease, hyperthyroidism, anemia, and infectious disorders [33]. Ginger herbal spray has been evaluated for its probable
effect on the management of dry mouth and associated disorders. In a clinical trial conducted
on type II diabetic patients (n = 20), patients were given ginger extract (ethanolic; 70% ethanol for extraction) to administer. Schirmer test was used to measure saliva. The results of
the study indicated a significant increase in the mean amount of saliva after ginger extract
administration. The study seems to be useful for patients suffering from dry mouth [34].
21.6.7
Anti-Pyorrhea Effect
Pyorrhea is a periodontal disease observed by inflammation and infection of bones and
ligaments that hold up the teeth. Gingivitis is also observed followed by plaque build-up
in the gums. The decay in the tooth forms the holes and pockets. Pockets trap food particles, the decay of which causes deepening of cavities. This causes erosion of bone leading to tooth loss. Gingerol, an active component of ginger, is evaluated for inhibition over
Porphyromonas gingivalis, Porphyromonas endodontalis, and Prevotella intermedia. The
minimum inhibitory concentration for [10]-gingerol and [12]-gingerol was in the range
of 6–30 µg/ml, and the minimum bactericidal concentration was 4–20 µg/ml, Figure 21.3.
The antimicrobial effect of [10]-gingerol was more than that of [12]-gingerol. The outcomes
of the present study concluded that the length and modification of the alkyl side chain of
gingerol is a key factor in determining antimicrobial efficacy [31].
21.6.8
Anti-Thrush Effect
Thrush or oral candidiasis is candidiasis of the mouth. It is a condition in which Candida
albicans accumulate at the linings of the mouth, observed by the production of white lesions
Ginger Powder
(in Tooth-paste/Tooth-powder)
Analgesic effect
Anti-gingival effect
Anti-tooth sensitizing effect
Figure 21.3 Analgesic effect of ginger.
336 Natural Oral Care in Dental Therapy
on the inner check and tongue. It can also affect the gums, tonsils, and throat. In a laboratory investigation, it was observed that ginger extract exerted an antifungal effect on
Candida albicans (Germ Tube formation Test). The extract at a concentration of 2 mg/ml
(in the dilution) (1:5) revealed an antifungal effect [35]. In another independent study,
Sunthi Churna (Ginger powder) extract (in 99% ethanol) was evaluated for its antifungal
effect. The extract was prepared by maceration at cold temperature as well as maceration at
room temperature. The lethality against Candida albicans was observed at log phase [36].
Supplementing ginger with chlorhexidine and calcium hydroxide reduced Candida albicans load [23].
21.6.9
Anti-Herpes Effect
Oral herpes is a viral infection, which is known to be caused by the Herpes Simplex virus.
The symptoms of the disease include swollen lips, gums, palate, and cheeks followed by pain
and inflammation. It is a contagious disease, which spread by saliva, mucus membrane, and
skin. Essential oil from ginger (concentration 0.003%) was evaluated for its anti-herpes
effect. The antiviral effect of ginger essential oil was due to the prevention of adsorption of
the virus before entry to the host cell. The essential oil interferes with the structure of the
virion envelop and possibly dissolved viral envelop. Microscopic investigation also revealed
the disruption of the viral envelop due to pretreatment with essential oil. The lipophilic
component of the essential oil interact with the lipid membrane, which influences envelop
integrity [37].
21.6.10
Tooth Polishing
Brushing teeth has become a habit for man. Shining white teeth bestow confidence. Tooth
polishing can be considered as an imperative division of dental procedures. Polishing of
teeth includes the smoothening of the surface of the teeth with simultaneous removal of the
deposition of plaque, biofilm, and acquired pellicle leading to the preservation of healthy
tooth health [38]. The process of tooth polishing aids in the removal of various exogenous
stains spawned due to food as well as environmental factors. Calcium carbonate, aluminum
silicate, calcium phosphate, pumice, etc., are used for tooth polishing [39].
Use of ginger in cleaning and polishing tooth has been advocated by Pierre Fauchard
(Father of Modern Dentistry). He suggested the use of a mixture of finely divided egg shell,
ground coral with ginger to polish the teeth [40]. The toothpaste formulation of ginger
extract has been patented. The toothpaste claims to provide better antibacterial and antiinflammatory effect when compared to conventional toothpaste formulation [41].
21.6.11
Mouth Deodorizing Effect
A mouthwash is a pharmaceutical preparation intended to be placed in the oral cavity and
rustled by the action of perioral musculature in order to eradicate the oral pathogens. The
history of mouthwash dates back to 460 BC. Hippocrates suggested the use of a mixture of
alum, vinegar, and salt to clean the oral cavity. In the present time, systemic study on ginger
mouthwash has been performed to evaluate its anti-gingival effect. A clinical study was
Ginger in Oral Care 337
Table 21.4 The patented toothpaste formulations of ginger.
Toothpaste formulation/invention
Claim
Reference
Salted ginger toothpaste
Against dental inflammation, bleeding,
halitosis,
[42]
Ginger extract and ginger oil
toothpaste
Reduction of dentin hypersensitivity
[43]
Toothpaste with honey and ginger
juice
Anti-inflammatory, prevent carries
[44]
Ginger toothpaste
Cleansing effect on teeth
[45]
Poly-herbal toothpaste containing
ginger
Against bad breath and gingival abscess
[46]
Attapulgite fresh ginger toothpaste
Removal of odor, reduction of dental
plaque, prevention of gingival bleeding
[47]
Poly-herbal toothpaste containing
fresh ginger
Reducing swelling and bleeding gums
[48]
Herbal toothpaste containing ginger
Reduction in swelling and in sore gums
[49]
Polyherbal Chinese herbs toothpaste
Prevention of tooth sensitivity and
mitigation action
[50]
Folic acid toothpaste containing
ginger
Postpartum gingivitis, bleeding gums
[51]
Children’s toothpaste
Oral care product for children with
better acceptance
[52]
Antiphlogistic toothpaste
Anti-inflammatory effect
[53]
Table 21.5 The patented toothpowder formulations of ginger.
Toothpaste formulation/invention
Claim
Reference
Polyherbal natural herbal tooth powder
Yellowing/staining of teeth, treatment
of pyorrhea, and Sensitivity of teeth
[54]
Dental powder with natural ingredients
Retarding tooth decay, relief from
tooth pain
[55]
Black attapulgite Chinese traditional
medicine tooth powder containing
ginger
Prevention of bleeding gums
[56]
Antiphlogistic and antitussive medicine
powder containing ginger
Prevention of foul breath,
preservation of dental health
[57]
338 Natural Oral Care in Dental Therapy
performed on 60 volunteers; 20 volunteers were divided into three groups and revived polyherbal mouthwash containing ginger, chlorhexidine mouthwash, and placebo mouthwash.
Outcomes of the study revealed that the polyherbal mouthwash containing ginger significantly improved the symptoms of gingivitis as evident from decreased scores of modified
gingival index, gingival bleeding, and plaque score [58].
21.6.12
Anticancer Effect
Ginger constituents have been extensively studied for anticancer effects. The protective
effect of 6-Shogoal was evaluated over 7,12-dimethylbenz[a]anthracene (DMBA)-induced
hamster buccal pouch carcinogenesis (oral carcinoma). Administration of 6-shogoal
(10, 20, and 40 mg/kg body weight) decreased over the expression of p53 and Bcl-2. There
was restoration of antioxidant status in animals and decrement in lipid peroxidation.
There was reversal of tumor incidences [59]. In another study of DMBA-induced oral carcinoma, there was inactivation of AP-1 and NF-κB followed by decrement in inflammation and cell proliferation [60]. In another study, [6]-paradol attenuated DMBA-induced
hamster buccal pouch carcinogenesis. Administration of [6]-paradol (30 mg/kg) for 14
weeks resulted in a decrease in neoplastic changes as well as restoration of bcl-2, p53,
TNF-α, and caspase-3 [61]. There was a decrease in lipid peroxidation and increase in
reduced glutathione in DMBA-treated animals [62]. Similar effects were seen in the case
of geraniol whereby peroxidation of lipids was decreased and restoration of phase I and II
enzymes was seen [63]. Similar findings were seen in the case of geraniol, which proved
to be anti-angiogenic, anti-cell proliferative, anti-inflammatory, and have apoptosisinducing properties [64].
21.6.13 Protection Against Aphthous Stomatitis
Aphthous stomatitis is a common painful condition, which affects the oral cavity. It is a
condition observed by persistence of benign mouth ulcers. The small, round, and multiple
ulcers are observed. It can develop due to trauma (dental procedures) [65], tobacco [66],
and certain drugs (phenobarbitone, piroxicam, nicorandil, gold salts) [67]. In some studies, ginger has been evaluated for its analgesic and anti-arthritic effect [68, 69]. In a study,
ginger-containing mucoadhesive system was evaluated for its efficacy in management of
aphthous stomatitis. It was a double-blind placebo trail enrolling 15 patients. The placebo
preparation contained tragacanth gum, and the ginger preparation consisted of an alcoholic
extract of ginger. These preparations were circular discs of 1-cm diameter. Patient volunteers
were asked to apply the preparation 20 min after every meal and before going to bed. The
treatment continued for a period of 7 days. The parameters for evaluation included determination of ulcer diameter, pain, and inflammatory zone. The outcomes of study revealed a
noteworthy decrease in pain. There was a significant decrease in pain on the fifth day. From
the first day of treatment, there was a notable decrement in inflammatory zone [70].
21.6.14
Effect on Dentin Hardness
Dentin is a calcified tissue, yellow in color, and is found in teeth along with the enamel, pulp,
and cementum. The enamel covers and protects the dentin [71]. The dentin is composed
Ginger in Oral Care 339
of hydroxylapatite, minerals, and water. It is produced by odontoblast forming a layer over
the pulp cavity. It forms the seat for the enamel [72]. The function of dentin is to protect
the pulp of the tooth [73]. Ginger is studied for its modulatory effect on dentin rigidity. In a
study, the effect of treatment with ginger (oil), sodium hypochlorite, and EDTA was evaluated on dentin hardness. The results revealed that ginger (oil) showed the highest reduction
in dentin micro-hardness. The study suggested the incorporation of ginger oil as an alternative to chemical irrigants in endodontics [74].
21.7 Pharmacokinetics
Table 21.6 Pharmacokinetics of gingerol.
Absorption
Oral
[75]
Distribution
Widely distributed
[75]
Metabolism
6-gingerdiol
[76]
Excretion
Urine
[77]
21.8 Toxicological Studies
Ginger in moderate amounts (up to 2 g) is safe for human consumption. The phytoconstituents of ginger, viz. gingerol and shogaol, are well absorbed and bio-transformed after oral
consumption [78].
21.9 Conclusion
Ginger has been extensively used in traditional medicines for treatment of various diseases. The use of ginger is documented to promote the process of food digestion, in
flu and cold, and in preventing nausea. The various forms of ginger like ginger slices,
grated ginger, ginger paste, ginger juice, and ginger oil are used. The contemporary
scientific research has validated this claim. Ginger also possesses anti-colon cancer
property. In view of oral health, ginger revealed a lethal effect on the growth of toothdecaying bacteria. It is a good dental analgesic and promotes dentine remineralization.
Antiplaque and mouth deodorizing effects of ginger are also well studied. The toothpaste and tooth powder of ginger help to keep teeth clean and remove tar-tar as well
as carries.
In nutshell, ginger has been reported to have varied pharmacological effects. However,
the specific mechanism of each activity is still unknown. Despite the lacuna of mechanistic
information, the usage of ginger seems to be innocuous and still is used widely for dental
and other therapeutic applications.
340 Natural Oral Care in Dental Therapy
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22
Effectiveness of Allium sativum on
Bacterial Oral Infection
Vesna Karic1,2, Anupam Jaiswal3, Heidi Abrahamse2*, Abhilasha Thakur3
and Aditya Ganeshpurkar3
1
Department of Prosthodontic and Oral Rehabilitation, and Laser Therapy in Dentistry Division,
School of Oral Sciences, Health Sciences Faculty, WITS University, Johannesburg, South Africa
2
Laser Research Centre, Faculty of Health Sciences, University of Johannesburg, Doornfontein,
Johannesburg, South Africa
3
Shri Ram Institute of Technology Pharmacy Jabalpur, Madhya Pradesh, India
Abstract
Garlic or Allium sativum is a species in the Allium genus. Its name is derived from an old
English word that means spear and leek. Garlic is found all over the world. It has some important chemical compositions that show various activities. The health benefits of consuming garlic are very well known. The use of A. sativum as an antibacterial agent and its effects on oral
flora are currently being studied in vitro and in vivo. The application of garlic in oral therapy
has shown promising results against Porphyromonas gingivalis and Actinobacillus actinomycetemcomitans and also on the proteases of Porphyromonas gingivalis that are found in periodontitis. Furthermore, in vivo studies have reported that mouthrinse containing garlic extract is
efficient in the treatment of Streptococcus mutans bacteria by reducing their complete count in
saliva. The ongoing interest in garlic as an oral antibacterial agent has grown since it appears
that the resistance of bacteria to garlic is much less than conventional antibiotics. It has also
been found that garlic has antifungal, anticancer, antiallergic, antiobesity, and antiviral properties. Garlic could conceivably become a treatment option for patients suffering from a variety of
oral diseases.
Keywords: Allium sativum, periodontitis, stomatitis, antibacterial, endodontitis, garlic, dental
22.1 Introduction
Petersen et al. described diseases in the oral cavities as a worldwide public health problem,
including dental caries and periodontal disease. Poor dental and oral health in patients has a
wider effect on general health and on the general quality of life [1]. Furthermore, dental caries
in most industrialized countries is considered a major health issue. It has been confirmed that
it affects 60% to 90% of children of school-going age and also clearly adults in great numbers.
*Corresponding author: habrahamse@uj.ac.za
Durgesh Nandini Chauhan, Prabhu Raj Singh, Kamal Shah, and Nagendra Singh Chauhan (eds.)
Natural Oral Care in Dental Therapy, (345–370) © 2020 Scrivener Publishing LLC
345
346 Natural Oral Care in Dental Therapy
Specific bacteria and constituents in the diet interact in the build-up of the biofilm plaque that
forms on tooth surfaces, which results in the formation of dental caries [2]. The first suggestion that infection causes dental caries was communicated by Clark. He described the causation
of dental caries: “by a hitherto undescribed streptococcus, Streptococus mutans.” Streptococcus
mutans is a gram-positive cocci, facultative and anaerobic, which can use carbohydrates from
food in the oral cavity to metabolize and grow. These microorganisms are the main cause of
dental caries. The formation of a cariogenic biofilm starts and ends with S. mutans on the surface
of the teeth because this bacterium uses sugar components, specifically sucrose, to form extracellular polysaccharides, which attach to glucan-coated surfaces [3]. S. mutans is also highly
acidogenic [4]. Hence, brushing of the teeth is very important because it has a great impact on
the removal of biofilm and reduces salivary levels of microorganisms, specifically S. mutans [5].
Dentists encourage a daily routine of brushing teeth at least two times per day. The mechanical
effect of brushing is necessary to remove plaque with cariogenic bacteria, and brushing with
fluoridated toothpaste is the first and most important line for the prevention of dental caries [6].
However, brushing of the teeth only will not be effective in completely removing bacteria
in the mouth. Additional steps are necessary, such as reducing the sugar intake in the diet
and rinsing the mouth with mouthwashes. The first recorded use of mouth rinsing is in
ancient Chinese medicine in 2700 BC [7]. Currently, the most established mouth-rinsing
liquid is chlorhexidine. This mouthwash has been in use for the last 20 years, with good
results in the reduction of dental caries. However, using modern scientific concepts, it
has become apparent that the formations of dental lesions are a result of complex interactions between inherited genetic factors and acquired environmental ones. Therefore, the
fight against dental caries and the prevention of dental caries diseases is augmented using
mouth-rinsing agents, which also play a key role in the prevention and treatment of periodontal disease. In addition, mouthwash is widely used for the treatment of pain, inflammation, and against the general population of pathogenic bacteria in the oral cavity [8].
Throughout recorded history, garlic (A. sativum) has shown efficacy in the field of dentistry due to its inhibitory effect on S. mutans in dental plaque [9]. The content of sulfur compounds found in garlic cloves such as allicin has been determined to be an antioxidant by the
chemical analyses of garlic cloves. Furthermore, sulfur compounds have the ability to attach
to the sulfhydryl (SH) groups in enzymes and proteins where it can modify their activities
and inhibit the sulfhydryl enzymes [10, 11]. It also has the capacity to occupy cells through
the cell membranes. The importance of finding better options for the treatment of dental
infections is because of the complexity of the microorganisms involved in the formation of
dental infections. An example is the Aggregatibacter actinomycetemcomitans, a gram-negative
bacterium, which is a primary cause of a severe form of periodontal disease, localized aggressive periodontitis [12, 13]. This bacterium has been connected recently to systemic infections
like urinary tract infection, osteomyelitis, and brain abscesses. The treatment of progressive
periodontitis is very difficult due to constant strengthening of bacteria resistant to antibiotics
[14]. A. actinomycetemcomitans is among other oral bacteria becoming resistant to antibiotics.
To gain a better appreciation of the current global health situation regarding the antibiotic resistance of many bacteria, specifically in dentistry, the issues like dental infection
epidemiology, dental infection, and antibiotic resistance and the antibacterial application of
garlic in dentistry need special attention.
The Indian subcontinent is the richest home to various plants, which have different
medicinal properties. For the last few years, some of them were used as Ayurvedic drugs for
Allium savitum on Bacterial Oral Infection
347
oral and dental care. The purpose of Ayurvedic medicine is to achieve physical, mental, and
spiritual wellness by holistic approach [15].
The antimicrobial activity of garlic has been recognized for centuries. In 1500 BC, it
was first identified in an Egyptian recipe known as Paprius Ebers. Garlic is used as a folk
medicine for the treatment of many diseases [16]. It is also used for the preservation of
food products [17]. The botanical name of garlic is Allium sativum belonging to the family
Liliaceae (Table 22.1). Its various active constituents are S-allycystein, alliin, allinase, allymethyltrisulfide, allicin, and diallylsulfide. Alliin is an amino acid in the presence of alline–
lyase catalyses, which is converted into allicin when the bulbs are crushed. Allicin, has a
specific odor, flavor, and some important pharmacological properties, which is used to treat
oral and dental problems because of the presence of sulfur-containing compounds. In the
presence of air, allicin is converted into diallyldisulfide, which is responsible for the bactericidal effect, and is reduced by cysteine, which will disrupt the disulfide bond in microbial
proteins. [18] Its bactericidal and bacteriostatic properties are mainly attributed to allicine
and thiosulfonate present in garlic, but some sulfur-containing compound decreases the
antibacterial activity [19, 20].
It has been reported that garlic has antibacterial, antifungal, antiviral, antihypertensive,
blood glucose lowering, antithrombotic, antimutagenic, and antiplatelet properties [21].
Pure garlic extract has greater antimicrobial properties compared to tetracycline against
Caecum bacteria. Garlic also has antifungal activity against Candida albicans, which is usually found in the oral cavity [22, 23].
22.1.1
History and Origin of Garlic
The name garlic is derived from the old English word that means a spear-shaped leek.
A. sativum is a species from the genus Allium. Garlic is closely related to onion, shallot,
leek, chive, and Chinese onion. There are several varieties of garlic, such as “wild garlic”,
“crow garlic”, and the “field garlic” found in England. In addition, families of A. ursinum,
A. vineale, and A. oleraceum demonstrate the types of garlic. There are about 120 different
garlic types from Central Asia, which make their diversity more complicated. A type of wild
garlic grows in North America as well [24].
Table 22.1 Scientific classification of garlic [41].
Kingdom
Plantae
Kingdom
Angiosperm
Phylum
Monocots
Order
Asparagales
Family
Liliaceae
Subfamily
Allioideae
Genus
Allium
Species
A. sativum
348 Natural Oral Care in Dental Therapy
It has been found that dietary content of 100 g of garlic has the highest percentage of
water (59%), followed by carbohydrates (33%), protein (6%), dietary fiber (2%), and a
minor content of fat (1%). It contains vitamins like B6 and C, as well as the dietary minerals manganese, iron, calcium, zinc, and phosphorous. Furthermore, garlic has certain B
vitamins (B1, B2, B3, B5, and B9). The general health advantages of consuming garlic are
therefore self-evident. However, disadvantages have emerged, too. For example, the longterm use of garlic may have side effects such as stomach discomfort or excessive excretion
of water from the body through sweating. Furthermore, the overuse of garlic could cause
increased bleeding and menstrual irregularities, as well as dizziness, and some people may
have an allergic reaction to garlic [25]. It has been found that the anticoagulant properties
of garlic in high doses may interact with certain anticoagulant medications, for example,
warfarin. Garlic can also negatively interact with anti-hypertensive medications, calcium
channel blockers, and the quinolone family of antibiotics (ciprofloxacin) [26].
Garlic has good medicinal properties. Since 2700 BC, garlic was used in China as one of
the most useful ayurvedic medicines because of its healing and stimulating effect. Garlic is
also used for the treatment of depression because of its stimulating effect. In Indian culture,
garlic was used as a folk medicinal remedy for the treatment of skin disease, cough, weakness, rheumatism, hemorrhoids, lack of appetite, and many other conditions. India follows
the various holistic concepts, and one of the very important holy books is Vedas. In this book,
it is mentioned that garlic is a medicinal plant. Furthermore, the Egyptians were very familiar
with so many aromatic, spices, poisons, and medicinal plants. Egyptians were very satisfied
with their own medicinal plants (their flora) that were located around the Nile River. Among
those, garlic was frequently used for the treatment of many different diseases [27, 28]. Garlic
is an irreplaceable nutritional supplement of the Egyptians. They fed their vassal with garlic to make them powerful and able of do more efficient work. It was used to heal wounds,
inflammation, and as a part of medicinal remedies in the ancient time. A carve of garlic bulbs
have been dated from 3700 BC, while the first appearance of garlic has been found in another
crypt from 3200 BC. In Ebers papyrus (around 1500 BC), lots of medicinal plants have been
found, and among others, the much recognized garlic, having a good capability to heal injuries. Further on, the ancient Greeks’ garlic was first discovered from 1850 to 1400 BC. The
earlier Greek army was used to be fed with garlic before battles. During the Olympic games,
the Greek athletes ate garlic to increase the chance of getting a good score [29, 30]. In addition,
the ancient Greeks used garlic as a medicinal remedy for the treatment of poor appetite, intestine parasites, anthelmintic, regulating the menstrual cycle, and other sickness. It has been
used for snake bites and dog bites, too. Hence, the Greek garlic is known as snake grass [31].
22.1.2
Medicinal Values of Garlic
Garlic has a moderate and pungent odor until it has been peeled. After peeling and crushing, its smell intensifies because of the presence of sulfur glycosides. When it comes in contact with the skin, initially, the heat is felt on the skin followed by a high pain or irritation. If
it is rubbed on the skin, the skin will get tanned. In 1892, it was reported that garlic contains
various unsaturated aliphatic sulfur compounds. In 1944, the compound allicin was isolated
from garlic by Cavallito and Bailey, and later on, it was confirmed that allicin has a powerful
antibacterial properties (Figure 22.1) against some gram-negative and gram-positive bacteria. In 1947, the chemical formula of allicin was developed, and in the same year, isolation
Allium savitum on Bacterial Oral Infection
Alliinase
349
Anti bacterial
effect
Garlic
Figure 22.1 Antibacterial activity of garlic.
of alliin was done, which was crystalline in shape and having no smell. Alliin gave the antibacterial effect by an enzyme alliinase from fresh garlic. Research studies have shown that
garlic has nutritional properties (Table 22.2) and can be used for the treatment of different
diseases. Some important components that are responsible for nutritional and medicinal use
of garlic (such as diallyl sulfide, ajoene, alliin, allicin, etc.) are cellulose, etheric oil, organic
acids, minerals (Mg, Zn, Se, germanium), water, amino acids, vitamins (C, A, from B complex), lipids, complex of fructosans (carbohydrates), enzymes, steroid saponosides, etc. [32].
In vitro studies have confirmed that garlic contains allicin and other sulfur compounds
that have effective antibiotic, antibacterial, and antimycotic properties [33, 34]. It was also
found that garlic is beneficial for the treatment of respiratory tract diseases and pulmonary
gangrene, and when treated with garlic tincture, the patient recovered within 17 days [35].
Research studies have shown that patients that used garlic were less prone to cold and more
resistant against colds when compared to patients on placebos [36, 37]. Garlic contains allicin
and other compounds that have hypolipidemic, antihypertensive activity, and hypocholesterolemic activity, and compound of Ajoenes that has an antithrombotic effect [38, 39].
22.2 Types of Allium sativum
Allium sativum (Figure 22.2) has two subtypes: Sativum, or soft-necked garlic and
Ophioscorodon, or hard-necked garlic (Ophios for short). The hard-necked garlic is an
original type of Allium sativum, and the soft necked is developed by cultivation. These are
further classified into the following subtypes:
22.2.1
•
•
•
•
•
22.2.2
Allium sativum Ophisocorodon/Hard-Necked Garlic
Purple Stripe
Glazed Purple Stripe
Rocambole
Porcelain
Marbled Purple Stripe
Allium sativum Sativum/Soft-Necked Garlic
• Turban
• Artichoke
350 Natural Oral Care in Dental Therapy
Table 22.2 Chemical composition of adult garlic [42].
Chemical composition
Nutritional value per 100 g
Carbohydrates
623 Kj
Sugar
33.06 g
Protein
0.5 g
Fat
2.1 g
Dietary fiber
1.00 g
Beta-carotene
6.39 g
Thiamine
5 µg
Folate (Vit. B9)
1.235 mg
Vitamin C
3 µg
Riboflavin (Vit. B2)
2 mg
Niacin (Vit. B3)
0.11 mg
Pantothenic acid (Vit. B5)
0.7 mg
Vitamin B6
0.596 mg
Calcium
31.2 mg
Iron
181 mg
Magnesium
1.7 mg
Phosphorus
25 mg
Potassium
153 mg
Sodium
401 mg
Zinc
17 mg
Selenium
14.2 µg
Manganese
1.672 mg
Figure 22.2 Buds/cloves of Allium sativum.
Allium savitum on Bacterial Oral Infection
351
• Creole
• Asiatic
• Silver skin [40]
22.3 Chemical Constituents
22.3.1
Allicin
Allicin is a sulfur-containing compound obtained from garlic. Allicin contains the
alkane thiosulfinic acid ester functional group, R-S(O)-S-R (Figure 22.3). This is a very
important compound responsible for its biological effect. This is formed by the enzymatic activity of alliinase on alliin. Allicin is a heat-sensitive compound, which is easily
broken down, especially if heated. Conversely, its breakdown can be slowed down by
refrigeration [43].
22.3.2
Ajoenes
Garlic has a medicinal compound (Figure 22.3) that contains allicin and some other compounds. They have, antihypertensive, hypolipidemic, and hypocholesterolemic activity
[39], and the Ajoenes have an antithrombotic effect.
22.3.3
Alliin
All natural drugs have nutritional properties as well as medicinal properties, which also
contain various chemical compounds for the treatment of the different diseases. One of
the important compounds of garlic is alliin (Figure 22.3). It is used to reduce bacterial
infection, fungal infection, and for oral infection. Alliin gives the antibacterial effect by the
presence of enzyme alliinase from fresh garlic [39].
O–
S
S+
Allicin
O
NH2
OH
S
O
Alliin
O
S
S
S
Ajoene
Figure 22.3 Chemical structure of allicin, alliin and ajoene
352 Natural Oral Care in Dental Therapy
22.4 Dental Infections and Epidemiology
Most of the head and neck space infections are of dental origin. The origin of these infections could be from the tooth and surrounding structures [44]. Dental infections, inter
alia, comprise the following: tooth caries, oral mucosa infections, periapical abscesses, periodontal abscesses, and the infection of the head and neck area. To complicate matters, the
general dental clinical health of the patient could be relevant, and a localized oral infection could be connected to a systemic infection. Vice versa, systemic infections could be
the cause of dental infection. The dental infection could affect the tooth crown, tooth root
structures, gingiva, and surrounding structures as seen in Figure 22.4.
The complexity of odontogenic infection increases due to the generally accepted scientific fact that odontogenic infection is never caused by only one organism. Therefore,
the polymicrobial nature of odontogenic infection complicates the treatment. For example, facultative anaerobes causing dental infection, specifically dentoalveolar abscesses,
include Streptococci viridans, Streptococus anginosus, Peptostreptococci, Prevotella, and
Fusobacterium species [45]. Dental abscesses are not a modern phenomenon, where microorganisms have been a part of the oral cavity in general.
22.5 Dental Infection and Antibiotic Resistance
Penicillin was discovered in 1928 by Sir Alexander Fleming, the first step in the modern era
of antibiotics. The first mass production of penicillin started in 1943, and after only 4 years,
patients started developing antibiotic-resistant microorganisms. This process has been
described as an evolutionary process [46]. The post World War II era has brought the world
a variety of new medication, including penicillin, which has cured many infectious diseases
and was perceived as a miracle by the people of that time. The infectious control measures
Tooth Crown
Gingiva
Tooth Root
Caries Lesion
Periodontitis
Figure 22.4 The radiographic view of dental caries, periodontis, root structures, and surrounding structures.
Allium savitum on Bacterial Oral Infection
353
that used to be applied before antibiotics, such as isolation, quarantine, and the scrupulous
application of aseptic technique, were largely discontinued, since antibiotics were curing all
bacterial infections. However, the evolution of resistance to antibiotics had already started.
When one antibiotic failed, another was prescribed, and so on.
However, today, we are faced with a more brutal truth, that most bacteria are becoming
resistant to antibiotics. Microorganisms have adapted to antibiotics, and they are evolving. In fact, bacteria are using antibiotics to boost their survival. Infectious disease treatment, previously effectively treated and caused by well-known microorganisms such as
Staphylococci, Streptococci, Escherichia coli, and Mycobacterium tuberculosis, has lost the
battle with the evolution of microorganisms, and they are now re-emerging as very dangerous diseases [47]. The infectious diseases of today are among the leading causes of patient
deaths worldwide. In the European Union, about 25,000 patients die every year from an
infection with the selected multidrug-resistant bacteria, and in the United States, every
year, more than 63,000 patients die due to hospital-acquired bacterial infections. Some bacteria are resistant to most common antibiotics, and antibiotics are of no use. A further consequence is that normal bacterial flora is changing uncontrollably as well [48].
The genetic plasticity of bacteria has pushed pathogens into adaptation mutation.
In Japan, during the 1950s, an epidemic of Shigellosis was induced by Shigella’s antibiotic resistance. Japanese scientists reported a few years later that resistance to “multiple
antibiotics not only developed quickly and simultaneously, but also seemed to transfer
from resistant to sensitive strains” [49]. The formation of the Antibiotic Resistance Genes
Database (ARDB) has confirmed 20,000 possible resistant genes [50]. One microorganism is not the only resistant agent. All categories of microorganisms are resistant to antimicrobials today. The apocalypse of antibiotic resistance of microorganisms is causing a
lot of issues with the medical and dental treatment of infection, and has changed fundamentally the antibiotic era’s way of treatment. There is a legitimate concern that we will
return to the pre-antibiotic era. The root of the issue is the negligence of the medical
and dental fraternity in the early years of antibiotic use, which has brought us to this
no-exit situation. It is a well-known fact that dental surgeons in the past used to prescribe a wide range of antibiotics, and frequently. The overprescribing of antibiotics has
promoted microbial resistance, hence, the permanent mutation and ongoing evolution of
microorganisms.
Human oral flora encompasses over 700 microorganisms. Some researchers have identified, with the aid of advanced technology, a rich microbial consortium and around 1000
diverse microbial species, which include bacteria, viruses, and fungi, in the dental biofilm.
However, among microbes existing in the oral biofilm, many are natural inhabitants [51].
However, antibiotic overuse and the formation of resistant microorganisms to antibiotics
in the treatment of dental infections have already caused severe complications. The appearance of penicillin in the market and clinical use has saved many lives throughout the planet,
transformed medical science and its success in treating infectious disease. However, the
abuse of antibiotics has taken the world on a different course, where antibiotic-resistant
bacteria are increasing the possibility of antibiotic-associated adverse reactions. The surge
of resistant bacteria has forced the medical and dental and scientific world to review the
protocols of treatment for any infection with antibiotics. Even chronic oral and dental diseases can be very dangerous, especially among immunocompromised patients. Coronary
heart disease, strokes, pneumonia, etc., are related to periodontal diseases and tooth loss
354 Natural Oral Care in Dental Therapy
that then increases the importance of applying more strict protocols to the use of antibiotics
for dental infections. For example, it has been found that endocarditis is linked to chronic
oral infections, particularly periodontitis. Furthermore, several studies have shown that
cardiovascular diseases such as coronary heart disease, stroke, peripheral vascular disease,
cardiomyopathy, atherosclerosis, and myocardial infarction are linked to chronic infection and inflammation. It has been shown that severe chronic microbial dental infections,
endocarditis, and meningitis are associated with cerebral infractions among male patients.
Therefore, the need for antibacterial agents is obvious. The new protocols are limiting the
treatment of infectious diseases with antibiotics but not offering any alternative solution.
Even though the incorrect and inappropriate use of conventional antibiotics is contributing
to the development of bacterial resistance that can endanger a patient’s health, we are left
with only one solution, namely, antibiotics, for treatment of infections [52]. Increasing the
need to develop natural therapies for the treatment of pathogenic microbial infection, one
such application is the use of garlic against oral diseases.
22.6 The Antibacterial Application of Garlic in Dentistry
The increase in bacterial resistance to antibiotics and the continuous struggle to control the
spread of infection in the human population has brought the attention of dentistry more
closely to herbal medication and more specifically to garlic.
22.6.1
The Use of Garlic to Treat Oral Infections
The history of garlic and a closer look at its composition has seen A. sativum as a more
favorable antibacterial medicament in dentistry, with specificity to periodontitis, dental
caries, endodotitis, children’s endodontitis, candidiases, and even oral cancer.
22.6.1.1
Periodontitis
Garlic is a known antimicrobial agent and its effects on oral flora have been studied in vitro
and in vivo. A study that examined garlic as a mouthwash using a sample of 30 patients,
who used a garlic solution mouthwash for 5 weeks, found inhibition of salivary S. mutans
multi-drug-resistant bacteria, which continued for 2 weeks after the end of the mouthwash period. However, the downside of garlic mouthwash is the unpleasant taste and halitosis [53, 54]. Garlic has emerged as a possible option for the treatment of oral bacterial
infections, since most oral diseases are due to bacterial infections. The primary content
of garlic is sulfide, and this is the reason that garlic is so beneficial for the treatment of
the oral bacterial infections. In dentistry, various mouthwashes like chlorhexidine have
been used successfully for antibacterial oral treatment. There have been research studies
that have tested garlic as an antibacterial mouthwash. In one study, they compared garlic extract and chlorhexidine mouthwash (0.12%), and it was found that they were both
effective against salivary microbial populations. However, chlorhexidine mouthwash
showed higher efficacy than garlic extract against salivary microbes [55]. The increase in
ineffectiveness of antibiotics against microorganisms has brought wider scientific attention to herbal antibacterial treatments, and interest in garlic as an oral antibacterial has
Allium savitum on Bacterial Oral Infection
355
grown since there have been no reports of resistance of microbes to garlic. Furthermore,
garlic has antifungal and antiviral properties. The application of garlic in oral therapy has
shown, in some studies, that garlic is effective against P. gingivalis and A. actinomycetemcomitans and on the proteases of P. gingivalis that are present in periodontitis. The garlic
constituent allicin has a major disadvantage in the therapeutic usefulness of garlic extract
in that it is unstable and breaks down at 23°C and within 16 h. This disadvantage of allicin could be improved by stabilizing the allicin molecule with the use of a water-based
extract of allicin. However, when water-based extract of allicin is used, allicin can react
with water to form diallyl sulfide, and that will result in allicin not having the same level
of antibacterial effect as the allicin that is not water based. Therefore, patients that have
periodontitis have bleeding gingiva, and this can compromise periodontal treatment with
antibacterial garlic due to the water content in the blood diminishing allicin’s antimicrobial
effects [56].
Another study used garlic extract to test its effects on oral bacteria and periodontal
pathogens. The results have shown that garlic extract killed P. gingivalis immediately, and
S. mutans was killed with a time delay. Furthermore, this study reported that the garlic
extract also inhibited the trypsin-like and total protease activity of P. gingivalis by 92.7%
and 94.88% [57]. Garlic has therapeutic value in the treatment of periodontitis and oral
infections. Furthermore, another research study demonstrated that daily consumption of
garlic will reduce gingival inflammation and gingival bleeding [58]. The search for potential
herbal treatment of A. actinomycetemcomitans associated with oral and non-oral infections
seems to stop with garlic extract because it significantly inhibits the growth of A. actinomycetemcomitans according to the research study that examined garlic extract against this
microorganism [59]. In summary, out of the seven research studies that have been reported
on the application of garlic in the treatment of periodontitis, only four studies have directed
research to only bacteria that cause periodontitis, while the rest of the studies included oral
bacteria, salivary bacteria, and S. mutans depicted in Table 22.3. The need for more research
studies is obvious from this summary. Garlic’s potential as an antibacterial treatment for
periodontitis should not be neglected.
The study reported that garlic extract of (57.1% w/v), containing 220 µg/ml of allicin,
inhibits the growth of gram-negative microorganisms, and the minimum bacteriostatic and
bactericidal concentration for the gram-negative strains was found to be allicin mean MIC
4.1 µg/ml, MIC range 35.7–1.1 mg/ml, and mean MBC 7.9 µg/ml. These data clearly indicates that garlic extract has a capacity to inhibit the growth of bacteria and some pathogens
that are present in the oral cavity, as well as proteases with therapeutic value for periodontitis [60].
Garlic shows antimicrobial activity. The disk diffusion method is used to determine
antimicrobial activity; four different concentrations of garlic extract have been used for
the evaluation (5%, 10%, 20%, and 100%) against Pseudomonas aeruginosa, Streptococcus
mutans, Streptococcus salivarius, Lactobacillus spp, and Streptococcus sanguis. Papers soaked
in 0.2% concentration chlorhexidine gluconate and saline were used as negative and positive controls, respectively. The result clearly indicated the zone of inhibition of the different
concentrations of garlic extract had similar effect. It might be concluded that using proper
concentrations of garlic extract in toothpastes or mouthwashes can be useful in the management of dental caries and periodontitis. The 5% of garlic extract is more useful as an
antimicrobial for dental carries compared to the other concentrations of garlic extract [61].
356 Natural Oral Care in Dental Therapy
Table 22.3 Research articles with application of garlic for treatment of periodontitis.
Disease/Microorganism
Outcome
[Ref]
Streptococcus mutans
Inhibition of organism in saliva
[53]
Streptococcus mutans
Unpleasant taste, halitosis
Garlic extract inhibited growth of Streptococcus
mutans
[54]
Salivary microorganisms
Both the garlic extract and CHX mouthwash
(0.12%) were effective against salivary microbial
[55]
P. gingivalis, A.
actinomycetemcomitans
The antimicrobial activity of garlic extract against
periodontal pathogens, P. gingivalis,
A. actinomycetemcomitans. Its action against
P. gingivalis includes inhibition of total protease
activity.
[56]
P. ginigvalis & Streptococcus
mutans
Garlic inhibited growth of microorganisms.
[57]
Salivary bacteria
Reduced gingival inflammation and bleeding
[58]
Aggregatibacter
actinomycetemcomitans
Growth inhibition
[59]
Various researchers are continuously working on garlic and their use in daily life.
According to a patent study, the essential oil of garlic and onion oil are used for smokers
for solubilizing and removing tobacco tars. Different concentrations of garlic and onion oil
mixture are used for the treatment of teeth, gums, tongue, and other surfaces of the oral
cavity as well as the dentures of a smoker [62].
22.6.1.2
Pediatric Endodontitis
A study researching the histopathological effects of garlic oil and formocresol on the pulp
tissue of the permanent teeth in pulpotomies in children revealed that teeth treated with
A. sativum oil showed inflammatory changes that had been resolved in the end of the study.
On the other hand, pulp tissue treated with formocresol eventually produced pulp necrosis,
and in some cases, pulp calcification was present [63]. This indicates that garlic offers less
aggressive healing potential, leaving the remaining pulp tissue healthy and functioning.
Garlic has been recognized as a natural remedy for many pathologic conditions because
of its anti bacterial, antimicrobial, and antioxidant effects. In a recent study, garlic is found
to be a novel therapeutic agent used to decrease inflammation of recurrent aphthous ulcer,
which is a very common ulcer of oral non-keratinized mucosa. Allicin is the important
component of garlic, which has an ability to decrease inflammation, pain, and heal ulcer to
prevent the recurrence of recurrent aphthous ulcer [64].
The study investigated teething symptoms in infants based on the interviews with mothers of infants—107 mothers were interviewed and reported that various symptoms arise
during teething. Furthermore, 91.6% of the mothers reported that teething symptoms arise
Allium savitum on Bacterial Oral Infection
357
with different symptoms; 90.7% stated that during teething, diarrhea symptoms arise. One
mother reported that she used paracetamol to relieve pain during teething, and 4.7% of the
mothers gave their children a pacifier, while a few mothers used home remedies like garlic
that they rubbed into the gum of the child. Dentists and health professionals should provide
more information about teething problems of infants and their misconceptions [65].
Another comparative study on garlic extract with sodium hypochlorite was performed
and evaluated for its possible smear layer removal. The study was carried out on 68 singlerooted mandibular premolars. They were divided into four groups, control (normal saline),
NaOCl (5%) with ethylenediaminetetraacetic acid (17%), garlic extract with EDTA, and
plane garlic extract. The outcomes of the study revealed that garlic extract as well as sodium
chlorite demonstrated a noteworthy use for the removal of the smear layer of root canal [66].
22.6.1.3
Dental Caries
Garlic extract is an effective antibacterial agent against S. mutans when tested both in vitro
and in vivo [67]. S. mutans is the main cause of dental caries, and it is of major interest to
the oral health struggle against the global pandemic of this disease. Therefore, garlic could
be an effective addition in the prolonged fight against resistant bacteria in the treatment
of dental infectious diseases. The in vitro study that used ethanolic extract of black garlic
on oral microorganism has confirmed good effects on microorganisms involved in oral
diseases. Hence, black garlic is a promising candidate for use in oral therapy to control the
biofilm associated with oral infections [68]. However, in another in vitro study, it was found
that garlic did not have a significant effect on S. mutans bacteria compared to the effects
seen using fig and mango [69]. The study that used plant extracts like garlic in crude form
suggested that garlic has potential for the control of S. mutans and can be used as an alternative remedy for dental caries prevention in the form of mouthwash [70]. Lemon and garlic
extract combination showed the greatest zone of inhibition against S. mutans compared to
other combinations like ginger and lemon [71]. Additionally, the findings of the study that
did research in children indicate that green tea and garlic with lime mouth rinse could be
an economical alternative to fluoride mouthwash for prevention and therapeutics against
S. mutans, Lactobacilli species, and Candida albicans [72]. In another study, clove oil was
the most effective of all products against microorganisms causing caries followed by ginger–
garlic paste and tea tree oil [73]. One research study has reported that garlic could be used as
an alternative to chlorhexidine as a disinfectant for toothbrushes [74]. The study that used
garlic extract that had a range of concentration between 40% and 70% assessed the inhibitory activity of garlic extracts on oral salivary microorganisms based on colony counts. The
results have confirmed a reduction of oral salivary microorganisms in an applied time range
of 30 and 60 s for 40% concentrations of garlic extracts in comparison to the control group.
The reduction of the exposed colony-forming unit was at 78% and 83.5% and for the 70%
concentrations, the reduction of oral salivary microorganisms was at 86.5% and 90.8% at
30 and 60 s. The conclusion of this study was that garlic extract is effective in the reduction
of an oral salivary microbial population. Furthermore, this study has proven that new antibacterial treatment options with fewer side effects are available [75]. The decision of what
dosage of A. sativum should be used for antibacterial therapy in dentistry is very important. For example, in one study, the broth dilution method revealed that planktonic growth
of the cariogenic, gram-positive species S. mutans, S. sobrinus, and Actinomyces oris were
358 Natural Oral Care in Dental Therapy
inhibited by an allicin concentration of 600 μg/mL or higher [76]. Therefore, more research
studies should be exploring the dosages of A. sativum for use in antibacterial oral application. However, one research study that tested chlorhexidine and garlic against oral microbials have reported that chlorhexidine and garlic only had antimicrobial activity against
S. mutans, but no positive results against other oral microorganisms [77]. However, there is
a need for much more research studies in vitro and in vivo that has to be done to get closer
to the proximity of regulated use of garlic for oral therapy.
Garlic has a good capacity in inhibition of oral bacterial growth with a mixture of lime
extract. This mixture inhibits the growth of seven bacterial species such as Norcadia asteroids,
Veillonella alcaligens, Lactobacillus acidophilus, Pseudomonas aeruginosa, Actinomyces viscosus, Staphylococcus aureus, and Streptococcus mutans. This study used standard technique in
vitro studies with carious teeth that were isolated from 240 extracted teeth. Compared with the
standard drug of Gentamycin (18.0 ± 0.0)–(23.0 ± 0.5), the mean zone inhibition for mixture
of both ranged from (15.0 ± 0.7)–(27.0 ± 1.0); (21.0 ± 1.0)–(27.0 ± 0.7) to (21.0 ± 0.7)–(30.0
± 0.5), respectively, showing antibacterial activity. MICs for a mixture of both (garlic and
lime) were 31.25–62.50 mg mL −1; 1:2 v/v and 15.63–31.25 mg mL −1, respectively, which
coincided with the respective MBCs. The result of the investigation suggested that the mixture of both garlic and lime could be used as a mouthwash for mouth sores and sore throat,
and it could also be used for the preparation of toothpaste to prevent dental caries [78, 79].
In another study, four different oils such as clove, garlic, neem, and tulsi were used to
study the disinfectant effect against Enterococcus faecalis. The study used 50 endodontic K
files and evaluated the antiseptic effect of different oils. The overview results of this study
concluded that garlic oil has more effective antiseptic effects against Enterococcus faecalis
compared to the other oil extracts [80].
22.6.1.4
Denture Stomatitis
Scientific research as early as 1955 has confirmed that C. albicans has became resistant to
all available treatments. Additionally, the overuse of antibiotics by dentists has increased
the chances of overgrowth of C. albicans [81, 82]. Denture stomatitis is a dental condition
caused by C. albicans.
Denture stomatitis is classified into three groups:
- Petechiae dispersed throughout all or any part of palatal mucosa in contact
with the denture as Newton type I.
- Macular erythema without hyperplasia as Newton type II.
- Diffuse or generalized erythema with papillary hyperplasia as Newton type III
[83].
The study that followed-up 11 patients at 1 month and 3 months after delivery of a new
prosthesis has confirmed the prevalence of denture stomatitis in 77.5% of patients [84].
A study that compared the antifungal effect of nystatin mouthwash with garlic aqueous extract in 40 patients has found that the erythematous lesions of denture stomatitis
improved in patients and recommended that garlic could be regarded as a suitable replacement for nystatin in the treatment of denture stomatitis [85]. Another clinical study has
used the essential oil of A. sativum and fluconazole for the treatment of each of 48 denture
Allium savitum on Bacterial Oral Infection
359
isolates. Their results have confirmed that the essential oil of A. sativum was effective against
all Candida types, but 4.2% of Candida species were resistant to fluconazole. This study has
confirmed that the essential oil of A. sativum is an effective agent against all Candida species
obtained from dentures. Additionally, an essential oil of A. sativum was effective to both
biofilm and planktonic cells in vitro [86].
Patients that suffer from denture stomatitis will have severe signs and symptoms as follows: erythema, edema, and swelling of palatal mucosa. Patients will not be able to eat and
that will then affect their digestive system. Therefore, the normal functioning of the patient
will be interrupted as long as the treatment of denture stomatitis lasts. The use of garlic for
the treatment of denture stomatitis could improve the outcomes of treatment.
Garlic is used as a home remedy. Sulfur is a main component in garlic. Various scientists claimed that it is responsible for the treatment of oral and dental problem. Another
study states that the oraganosulfur compound has a powerful antibacterial effect. The study
demonstrated that garlic oraganosulfur compound, converted into nano-iron sulfide compound, has a capability of inhibiting topical bacterial infection on teeth and is also responsible for faster wound healing [87].
22.6.1.5
Protection Against Fibrosis
A study that examined the efficacy and safety of allicin treatment of stage II oral submucous fibrosis (OSF) reported a decrease in the burning sensation experienced by patients.
The study was based on randomized clinical trials using allicin or Triamcinolone acetonide (TA) that was injected into the lesion weekly for 16 weeks. Forty-eight subjects were
used, and at 40 weeks, it was found that the mouth opening was 5.16 ± 1.04 mm in the
allicin group and 2.27 ± 0.84 mm in the TA group. Furthermore, the burning sensation
improved by 4.33 ± 1.04 in the allicin group and by 2.79 ± 0.87 in the TA group. The OHIP14 score increased by 12.58 ± 9.82 in the allicin group and by 4.67 ± 2.94 in the TA group.
This study showed a reduction in the burning sensation of the mouth as well as improved
opening of the patients’ mouth after administration of Allicin intralesional injections [88].
22.6.1.6
Garlic Chewing Gum
Black garlic has rich antioxidant, vitamins, and nutrients compared to white garlic. It is more
effective against heart disease. It has been patented for use in chewing gums. Raw materials
are used in different weight ratios such as L-arabinose 8–15 1–7 3.1–2 part by tea polyphenols
discretion 2–7 parts soya lecithin 10–20 sorbitol, 12–20 xylitol parts, citric acid, sodium erthorbate 1–4 1–3 40–50 parts gum base, which is used for many purposes like antibacterial,
antimicrobial, lower cholesterol, reduce weight, stabilize blood pressure, etc. [89].
22.6.1.7
Garlic Used as a Breath-Freshening Agent
Scientists are frequently researching on most of the medicinal drugs, and one of the important components is garlic. Garlic has a medicinal as well as nutritional value. According to a
recent study, garlic is used in breath freshening toothpaste. By weight, garlic extract is 0.005%
to 0.05%, and the composition of toothpaste is calcium carbonate, glycerin, sodium carboxymethyl cellulose, sodium silicate, sodium lauryl sulfate, sorbitol, flavors, saccharin, garlic
360 Natural Oral Care in Dental Therapy
oil, and deionized water. This invention says that garlic extract is not only used for respiratory
and oral cavity drug stabilization but also as bactericidal antidrug toothpaste [90].
Halitosis is a quite unpleasant condition that makes the person uncomfortable. Halitosis
is produced by bacteria, which are part of the oral cavity flora. Various natural food are
available to overcome oral malodor. Halitosis is not only found in humans, but it is also
present in animals. One of the patent studies says that the administration of raw garlic has
a capacity to reduce and control oral malodor in pets such as dogs [91].
In a study, five toothbrush disinfectants containing tea tree oil, chlorhexidine gluconate,
cetylpyridinium chloride, garlic extract and UV toothbrush-sanitizing device, and garlic
were evaluated for its possible inhibitory effect against Streptococcus mutans. The study
was carried out on dental students (120 were administered with the test formulations as
mentioned above). The treatment continued for 2 weeks, and evaluation of antibacterial
effect was determined. The outcomes of the study revealed that garlic extract was more
effective over the growth of the bacteria compared to other antimicrobial agents [92].
In another study, three mouthwashes containing chlorhexidine gluconate, triphala, and
garlic were evaluated for its possible inhibitory effect against Streptococcus mutans. The
study was carried out on children (60), with ages from 9 to 12 years, who were administered
with the test formulations as mentioned above. The treatment continued for 15 days and
evaluation of inhibition of “plaque buildup” was determined. The outcomes of the study
revealed that garlic extract as well as chlorhexidine demonstrated a noteworthy inhibition
over the growth of the bacteria [93].
22.7 Additional Use of Garlic in Dentistry—Oral Cancer
The diet plays a significant role in cancer etiology and its prevention; this has been confirmed many times in the modern world. However, garlic has been used for medicinal purposes (Figure 22.5) over 5000 years. It is claimed that even the incidence of cancer can be
reduced substantially by means of dietary modification including using garlic as part of the
diet. History records the use of garlic in 1550 BC in Egypt as a treatment for tumors. When
the Israelites fled Egypt, the Bible mentions garlic as a medicine. Even Hippocrates considered garlic to be a vital part of medicine [94].
The consumption of garlic extracts exerts a protective effect against various types of
cancer, including prostate, colon, and oral cancers, this was established by epidemiological studies [95, 96]. The most prevalent type of cancer in the world is oral cancer. This
is the sixth leading cause of cancer-related mortality in the United States of America
with one death per hour [97]. The search for alternative treatments of oral cancers and
use of garlic has been investigated in a few studies. The study that used S-allylcysteine
to suppress tumor in mice has reported that oral cancer was significantly suppressed
in growth and progression, in the mouse xenograft tumor model of oral cancer. In this
study, human oral cancer CAL-27 cells were grown at 37°C in a 5% CO2 incubator. In this
study, they used single-cell suspensions with a viability of 90% for the injections into the
mouse. During the research period, the mouse was fed with Lab diet 5010 and the diet
did not have S-allylcysteine. Additional to the findings of tumor inhibition in the mouse,
S-allylcysteine also decreased the osteopontin plasma level in tumor-bearing mice [98].
Allium savitum on Bacterial Oral Infection
361
O
OH
H
CARDIOPROTACTIVE
(R)
S (S)
H2C
CANCER
NH2
O
ANTI-ALLERGIC
ANTI-OBESITY
ANTI-OXIDANT
ANTIFUNGAL
Figure 22.5 Pharmacological potential of garlic.
The very aggressive oral squamous cell carcinomas that originate from the mucosal
surfaces of the oral cavity make out more than 90% of all head and neck cancers in the
world [99]. The in vitro research study that applied S-allylcysteine to incubated oral squamous cancer cells at dosage levels of 0, 5, 10, and 20 mM for 24 h has confirmed that
S-allylcysteine effectively inhibits the proliferation and malignant progression in human
oral squamous cancer cells. Therefore, S-allylcysteine for human oral squamous cancer
cells could be a future treatment option [100]. A. sativum could become one of the treatment options for oral cancer treatment. Crude garlic extract is used to reduce the risk of
cancer. According to a research, mice were used for a study of cancer and were infected
with cancer cells, and another group of mice was treated with garlic extract. The mice
which were not given garlic died within 6 days; the other mice which were given garlic
extract survived for 6 months [101].
22.7.1
High Blood Pressure
High blood pressure is also known as hypertension. The patients often do not know that
they have high blood pressure, and they will die. This is the reason why this condition is
called a silent killer. The high blood pressure is a chronic condition with bad effect on the
vascular system. Various home remedies that have medicinal properties are available in the
market. Among all these remedies, garlic is one of the most effective medicinal remedies for
high blood pressure [102].
362 Natural Oral Care in Dental Therapy
22.7.2
Skin Disorders
These days, acne is the most common problem in adult as well as in the elder person.
Garlic has properties to reduce pimple spots, and it is helpful in clearing the skin from
acnes. Acne is a chronic inflammatory disease of the pilosebaceous follicles involving
altered follicular keratinization, androgen-induced sebaceous hyperplasia, hormonal
imbalance, hypersensitivity of immune system, and bacteria (Propionibacterium acnes)
colonization [103, 104].
Immunomodulator—Garlic has medicinal remedies. It is used as an immunity-boosting
agent. Various scientists researched on garlic, and they concluded that garlic has an immunomodulatory effect [105].
22.7.3
Anti-Allergic
Garlic has been used in India since ancient time and all over the world. Garlic is used in
many diseases because of the presence of many chemical compounds. One of the important properties of garlic its use as an anti-allergic for the treatment of allergy as well as an
anti-oxidant—a substance that has a capability to reduce oxidation and prevent cell damage
by free radicals [106].
22.7.4
Anti-Obesity
Obesity is an excess fat accumulated in the human body, and it could have various side
effects on health. Obesity is the leading cause of various diseases such as heart attack,
high blood pressure, asthma, etc. Garlic is used for reduction of body fat due to its good
medicinal properties. Garlic can reduce cardiovascular risk—cardiovascular disease is
a condition in which the risk of heart failure is due to blockage of blood vessels, narrowing of passage, and excess pressure on the heart. Garlic has been found to be a good
medicinal remedy for the reduction of the risk of cardiovascular disease. A clinical study
reported that garlic powder has a capacity to reduce multifunctional cardiovascular risk
[107, 108].
22.8 Garlic Mechanism of Action
Garlic is an herb that contains various chemical compounds. Allicin is a compound that has
a capability to inhibit bacterial growth (Figure 22.6). In the presence of allinelyase enzyme,
allicin converted into diallyldisulfide inhibited the synthesis of DNA and RNA and stopped
the growth of bacteria [109].
22.9 Conclusions and Recommendations
In conclusion, garlic has emerged as a possible option for the treatment of oral bacteria.
Considering that most of the oral diseases are due to bacterial infections, this could be of
great benefit to the patients. The crisis of antibiotic resistance has already forced dental
Allium savitum on Bacterial Oral Infection
363
ALLICIN
ALLINE-LYASE
DIALLYLDISULPHIDE
INHIBIT DNA & RNA
SYNTHESIS
INHIBIT GROWTH OF
BACTERIA
Figure 22.6 Mechanism of action in antibacterial effect of garlic.
research to explore garlic as an option of treatment. A. sativum has been proven by many
research studies as an available option for antibacterial treatment of oral diseases. The
postulation that garlic is capable of killing oral flora in its complexity is one huge step
forward for the treatment of oral diseases, bacterial, fungal, and oral cancer. However,
the line between advantages and disadvantages of the use of garlic in dentistry needs to
be explored. Additionally, formulation of appropriate dosage and delivery systems for
antibacterial garlic application must be confirmed. The implication of garlic being used
with any patient’s chronic medications has to be explored. A. sativum interaction with
dental treatment medications and local anesthetic has to be investigated. Garlic, as an
anticoagulant, and its effect on patient health need to be confirmed. The protocol for
preventative and therapeutic application of garlic in dentistry needs to be developed and
confirmed (Figure 22.7).
Nausea
Diarrhea
Sweating
Burning of the
mouth
Vomiting
Figure 22.7 Side effects of garlic [110].
364 Natural Oral Care in Dental Therapy
Acknowledgments
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: this work is based on the research supported by the
South African Research Chairs Initiative of the Department of Science and Technology and
National Research Foundation of South Africa (Grant No. 98337). The authors sincerely
thank Miss A. Crous and Dr. R. Chandran for all the editing support and the University of
Johannesburg, Laser Research Centre, for the infrastructure.
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Part IV
ETHNOBOTANY AND
ETHANOPHARMACOLOGY
23
Curative Plants Worn in the Healing of Mouth Evils
P. Shivakumar Singh1*, Pindi Pavan Kumar2 and Dasaiah Srinivasulu2
1
Department of Botany, Palamuru University, Mahabubnagar, Telangana State, India
Department of Microbiology, Palamuru University, Mahabubnagar, Telangana State, India
2
Abstract
Mouth evils, an unpleasant breath odor can become a serious problem affecting an individuals’ social
communication and self-confidence. Furthermore, it is a discomforting issue for the people around
the person affected because they consider it embarrassing to inform the person of the problem. This
chapter reports on an ethno botanical survey that was conducted in the landscape of Kosgi Mandal
of Naryanapet District, Telangana State, India, where these studies were nonexistent. The information is documented with a respective scientific questioner. At the time of field documentation, the
location, season, and plant parts were collected, and the mode of preparation and usage of the medicine were taken via interview with the practitioners. In thi s study, a total of 32 traditional medicinal plants, which have been used in the treatment of mouth evils were documented. The results
showed that the 32 plants species belong to 31 genus, and 22 families were occupied. The plant families are represented in their increasing order, i.e., Fabaceae, Euphorbiaceae, Apiaceae, Lythraceae,
Lamiaceae, Myrtaceae, and Verbenaceae, and the 15 families correspond to the single species. The
results give further ethno pharmacological studies for the discovery of potential new drugs.
Keywords: Rural, curative plants, mouth evils, narayanapet, telangana
23.1 Introduction
The skill of traditional medicinal treatment is very deep rooted in Indian culture, and the
plants are used not only for remedial diseases but also during various ceremonies. Right
through man’s history, people have relied on traditional medicine and folkloric plants,
in particular, to promote and maintain good health. This dependency of man on plants
made him obtain knowledge regarding the medicinal properties of plants by trial and error
methods.
The World Health Organization (WHO) has predicted that most of the world population
is still reliant on traditional medicine for their primary health needs [1]. People living in
developing countries rely quite effectively on traditional medicine for primary health care
[2, 3]. The art of herbal treatment has very deep roots in Indian culture, and plants are
used not only for curing diseases but also during several ceremonies. Nowadays, the world’s
*Corresponding author: shivakumarsinghp@gmail.com
Durgesh Nandini Chauhan, Prabhu Raj Singh, Kamal Shah, and Nagendra Singh Chauhan (eds.)
Natural Oral Care in Dental Therapy, (373–382) © 2020 Scrivener Publishing LLC
373
374 Natural Oral Care in Dental Therapy
population follows the ethno medicinal system because of its effectiveness, security, and
lesser side effects. Due to the rising national and international demand, medicinal plants are
facing permanent exploitation from their natural habitats [4]. Medicinal plants are essential
natural resources, which constitute one of the potential sources of new products and bioactive compounds for drug development [5].
Traditional medicinal uses contribute significantly to such drug development. It is estimated that about 60% of the world’s population and 80% of the population of developing
countries rely on traditional medicine for their primary health care needs [6]. Nowadays,
there is an increasing desire to unravel the role of ethno-botanical studies in trapping the
centuries-old traditional folk knowledge as well as in penetrating new plant resources of
food, drugs, etc. [7]. India is a warehouse of medicinal plants. At present, about 65% of
Indians are dependent on the traditional system of medication [8].
Mouth evils are an extremely universal stipulation that influenced the common people in
their everyday life. has gone a long way, i.e., mouth rinses, oral cleanliness, oral vigor, oral
illness, mouth evils, dental caries, and periodontal illness [9].
23.2 Materials and Methods
The study area selected was a forest location, rural-indigenous communities, and
lack of documentation. There were no previous reports on the medicinal plants used
against mouth evils. Overall, there were 12 months in every session. Frequent visits
Adilabad
Kumuram Bheem
Nirmal
Mancherial
Jagtial
Nizamabad
Kamareddy
Medak
Peddapalli
Rajanna
Sircilla
Siddipet
Bhadradri
Kothagudem
Jangaon
Sangareddy
Medahar
Hydraband
Yadadri
Bhuwanagiri
Nagarkurnool
Figure 23.1 Study area, Telangana, India.
t
Nalgonda
Jogulamba
Gadwal
Khammam
e
ap
ry
Rangareddy
Mahabubnagar
Mahabubabad
Su
Vikarabad
Wanaparthy
Jayashankar
Bhupalpally
Karimnagar
Curative Plants Worn in the Healing of Mouth Evils
375
were made for the documentation of rural medicinal plants with the help of local practitioners in every season. These types of approach would elucidate the collections,
preservations, and identifications. At the time of field documentation, the location,
season, and plant parts were collected, and the mode of preparation and usage of the
medicine were taken via interview with the practitioners using local flora [10–14].
The serenaded medication with plant samples was deposited at predictable herbarium
centers. The voucher numbers allocated for the herbarium samples were deposited.
The current chapter approach reveals the Telangana state, Narayanapet Dist., Kosgi
Mandal (Figure 23.1). The Mandal area occupies 242.0 sq. km, has a population of
48,299, and a density of 200 (per sq. km). The plant diversity is very rich dealing with
a variety of sickness together with mouth evils. Consequently, the current research outcome has given attention to the certification of rural medicinal plants in the healing of
mouth evils.
23.3 Results and Discussion
The present results reveal that a total of 32 rural therapeutic plants have been documented
from the selected study area of Kosgi Mandal, Narayanapet Dist., Telangana State, India.
Through the regular interactions of medicinal practitioners and healers in the rural areas,
successful collection, preservation, and authentications were made with the help of local
flora. The 32 therapeutics species belong to 31 genera covered, whereas 22 families have
been occupied with their systematic positions in the botanical studies.
Detailed information regarding rural medicinal plants used in treating mouth evils are
given in Table 23.1. The name of the family, plant scientific name, plant local name, and
part used are carefully documented and authenticated in the presence of a rural medicinal
practitioner. After the collection of the specimen plants from the field, the plants were used
in the herbarium preparation. The herbarium specimens have been documented, and they
were carefully preserved in the Department of Botany, Palamuru University, Mahabubnagar
Telangana State.
The fraction allocation of a variety habitat was trees 13 sps., shrubs 10 sps., herbs 08 sps.,
and climbers 1 sps (Figure 23.2). The incidence allotment foundation of curative plants
publicized 32 sps. comes under Cultivated, Wild 15 sps. Wild, 09 Cultivated 08 sps (Figure
23.3). The proportion of entity cluster was intended. The past testimonies of Lawsonia Maji
Jose et al., Jatropha [15, 16], Hebber et al., [17] Chopra RN et al., [18] Cinnamon [19], and
Sonowal [20] supported the in attendance donations.
Data were compared with the available previous literature and found that many of the
usages listed were not recorded earlier [21]. In the previous scenario, there were no reports
on mouth ulcers from the current study area. This is the first and exclusive report. Frequency
in distribution sources, percentage in the distribution of growth forms, distribution of therapeutic plants into taxonomic groups, and frequency in the distribution of plant parts of
therapeutic plants against mouth ulcers were analyzed.
In the present report, Lawsonia inermis L. leaves were used with some ingredients
in the preparation of mouth ulcer-treating drugs, but in the previous, Maji Jose et al.
used only leaves. In some of the previous reports that were also documented, Jatropha
curcas L. latex was used in the treatment of mouth ulcers [22]. The Rajasthan rural
Family
Plant name
Voucher
number
Parts used
Local name
Mode of use and suggested medical
practitioner
Annonaceae
Annona squamosa L.
HPU-19
F
Seetha
phalamu
Leaf and young flower chew daily morning
empty stomach for 4–5 days
Papaveraceae
Argemone mexicana L.
HPU-61
L
Pasupu alamu
Young root juice is applied on top of sores
Miliaceae
Azadirachta indica
HPU-14
B
Vepa
Olden bark beneath red bark juice is pertain on
mouth evils thrice for 4 days
Rutaceae
Bergera koenigii L.
HPU-51
L
Karivepaku
One spoon of unsullied bark juice with 1 spoon of
honey is occupied two times a day for 3 days
Fabaceae
Butea monosperma
(Lam.) Taub.
HPU-50
L
Moduga
Petiole decoction mouth pulling twice a day
Fabaceae
Cajanus cajan (L.)Mill.
HPU-515
L
Kandulu
5 leaves twofold a day for 6 days
Ceasalpiniaceae
Cassia alata L.
HPU-33
L
Avisha
Decoction of young leaves is worn mouth
pulling for 5 days
Arecaceae
Coccus nucifera L.
HPU-12
F
Kobbara
Dried up coconut squash thrice a day respite as
of evils ache
Apiaceaet
Coriandrum sativum L.
L.
HPU-22
A
Kottimira
Gnaw ariel-stem fractions once a day until it is
cured
Apiaceae
Cuminum cyminum L.
HPU-74
S
Jera
4 spoons of jera drenched in 200 ml of water
with crystalloid sugar full of night and intake
with drain stomach for 3 days
Moraceae
Ficus bengalensis L.
HPU-80
L
Merri
Young leaves chomp bestows respite from
mouth evils
(Continued)
376 Natural Oral Care in Dental Therapy
Table 23.1 The medicinal plants used in treating mouth evils.
Table 23.1 The medicinal plants used in treating mouth evils. (Continued)
Parts used
Local name
Mode of use and suggested medical
practitioner
Gymnosporia montana
(Roth) Benth
HPU-34
L
Dantha
Leaves chewed once a day for 3 days
Euphorbiaceae
Jatropha curcas L.
HPU-27
Lt
Adavi-amudamu
Stem latex applied on top of mouth evils
Asteraceae
Launaea procumbens
(Roxb).
HPU-48
L
Atavika gabi
The boiled leaves juice like 10 ml is taken with
empty appetite for 3 days
Lythraceae
Lawsonia inermis L.
HPU-94
B
Gorintaaku
Young leaves of Lawsonia and equivalent sum
of black jera were complete hooked on soft
glue add crystal sugar combine fit, prepared
tiny pills after that acquire every day two
times morning with unfilled stomach & night
sooner than departing to bed
Anacardiaceae
Mangifera indica L.
HPU-52
S
Mamedi
Ripen fruit kernel paste is useful to the mouth
evils every day 2 times
Lamiaceae
Mentha viridis L.
HPU-10
L
Pudina
One spoon of dried leaves fine particles with
humid water is used in unfilled stomach for
3 days
Cucurbitaceae
Momordica charantia
L.
HPU-84
F
Kakara
2 spoons of dehydrated ripened produce soft
tissue with half spoon of lemon sap assorted
in roughly as regards 200 ml of water is in
use two times a day for a 5 days
Lamiaceae
Ocimum sanctum L.
HPU-532
L
Thulasi
Seeds, curcuma has taken equivalent quantity
and finished soft paste put in one teaspoon of
unsullied honey
Plant name
Celastraceae
377
(Continued)
Curative Plants Worn in the Healing of Mouth Evils
Voucher
number
Family
Family
Plant name
Voucher
number
Parts used
Local name
Mode of use and suggested medical
practitioner
Euphorbiaceae
Phyllanthus emblica L.
HPU-92
F
Nila usiri
1 spoon of young fruit juice & 1 spoon of sugar
through 100 ml of water for two times a day
are taken for 4 days.
Euphorbiaceae
Phyllanthus reticulates
Poir.
HPU--34
B
Polichera
Olden stalk bark cover masticate heal the
mouth evils
Fabaceae
Pithacalobium dalsi L.
HPU-77
F
Sima
Consume 3 juvenile fruits twice a day, it heals
mouth evils without delay
Myrtaceae
Psidium guajava L.
HPU-78
L
Jaama
Boiled leaf juice is whoosh each morning for a
week
Lythraceae
Punica granatum L.
HPU-79
S
Danimma
2 teaspoons of young bark powder, smidgen of
curcuma dust add to tea cup of cow milk &
taken earlier than departure to bed, for 3 days
Solanaceae
Solanum nigrum L.
HPU-83
L
Keshobusa
The fresh leaf paste, applied on mouth evils two
times a day for 2 days
Myrtaceae
Syzygium aromaticum
(L.)
HPU-88
F
Levangalu
Young flower bud juice by honey is applied on
evils once a day for 4 days
(Continued)
378 Natural Oral Care in Dental Therapy
Table 23.1 The medicinal plants used in treating mouth evils. (Continued)
Table 23.1 The medicinal plants used in treating mouth evils. (Continued)
Plant name
Voucher
number
Parts used
Local name
Mode of use and suggested medical
practitioner
Verbenaceae
Tectona grandis L. f.
HPU-84
L
Teeku
Leaf base chew up cures mouth thrice a day,
until it cures evils
Combretaceae
Terminalia chebula L.
HPU-86
F
Karakkye
Olden fruit glue is assorted amid honey and
applied on evils; it heals in 3 days
Fabaceae
Vachellia nilotica (L.)
P.J.H. Hurter & Mabb.
HPU-89
L
Krishna thuma
Chew up the fresh gum, alleviates mouth evils
Verbenaceae
Vitex negundo L.
HPU-101
B
Vaela
Chew up 2 juvenile vegetation every day one
time for 3 days
Zingiberaceae
Zingiber officinale
Rosce.
HPU- 100
R
Allamu
1 teaspoon of clean rhizome sap through half
tea spoon of honey intakes two times a day
Rhamnaceae
Zizyphus jujuba Lam.
HPU- 60
L
Niradu
Drag of historic foliage boiled water for 3–4
days treats mouth evils
Curative Plants Worn in the Healing of Mouth Evils
Family
379
380 Natural Oral Care in Dental Therapy
50
40
30
20
10
0
Herbs
erbs
Shrubs
Trees
Climbers
Figure 23.2 Fraction allocation of augmentation variety of remedial foliage adjacent to mouth sore.
Figure 23.3 Fraction allocation of augmentation habitual of remedial foliage adjacent to mouth sore.
people are using Jatropha species in routine oral treatments [23]. Hebber et al. [24]
reported that 35 plants belonging to 26 families were used to treat different oral ailments from the Western Ghat region of Dharwad District of Karnataka. Chopra RN
et al. [25] reported on the traditional therapeutic plants curing dental caries. Cinnamon
has been reported to scientifically reduce the growth of oral microbes [26]. Sonowal
Kachari [27] decrypted two therapeutic plants for mouth cleaning from the tribe of
Dibrugarh District in Assam [28].
The ascending order-representing families are Fabaceae, Euphorbiaceae, Apiaceae,
Lythraceae, Lamiaceae, Myrtaceae, and Verbenaceae. At the same time, 15 families represented single species. At the time of field documentation, the location, season, plant parts
collected, the mode of preparation, and usage of the medicine were gathered via interview
with the practitioners. The results give tremendous fundamentals for further authentication
studies.
Curative Plants Worn in the Healing of Mouth Evils
381
23.4 Conclusion
Rural medicinal plants are the source for future research. The present chapter reveals rural
therapeutic information. Rural medicinal plants, which were used against mouth evils, can
be used in the rural area of the selected area. The documented information will be very
much useful to upcoming researchers.
Acknowledgment
The authors are grateful to the rural healer citizens of Kosgi Mandal, Narayanapet Dist.,
Telangana State, for sharing their insights on counteractive foliages.
References
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Gulbarga, 2010.
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of Mayurbhanj District of North Orissa. Ethno-Med., 3, 1, 27–32, 2009.
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in Coastal Dakshina Kannada. J. Oral Health Community Dent., 5, 3, 119–123, 2011.
16. Bhasin, V., Oral Health Behaviour Among Bhils of Rajasthan. J. Soc. Sci., 8, 1, 1–5, 2004.
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India. Plants used in oral health care. J. Ethnopharmacol., 94, 261–66, 2004.
18. Chopra, R.N., Chopra, I.C., Handa, K.L., Chopra’s indigenous drugs of India, 2nd ed., UN Dhur
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19. Saeki Ito, Y. and Okuda, K., Antimicrobial action of natural substances on oral bacteria. Bull.
Tokyo Dent. Coll., 30, 129–35, 1989.
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24
Ethnopharmacological Applications of
Chewing Sticks on Oral Health Care
E. A. Akaji 1* and U. Otakhoigbogie2
1
Department of Preventive Dentistry, Faculty of Dentistry, College of Medicine, University of Nigeria,
Ituku-Ozalla, Enugu, Nigeria
2
Department of Oral Pathology and Oral Medicine, Faculty of Dentistry, College of Medicine,
University of Nigeria, Ituku-Ozalla, Enugu, Nigeria
Abstract
The role of natural devices such as chewing sticks with a pedigree of good oral hygiene and antimicrobial activities in oral health therapy is apt. Chewing sticks are used worldwide for tooth-cleaning but
more prominently in African and Asian communities, and their use dates back to prehistoric times.
They are derived from a variety of plants containing bioactive agents with fewer side effects than
the conventional antimicrobial agents. Constituents of these sticks such as tannins, anthraquinones,
fluorides, salvadorine, resins, silica, trimethylamine, and essential oils reduce plaque formation and
bacterial growth in the oral cavity; they are therefore invaluable in circumventing and controlling
oral infections. Trimethylamine and salvadorine contents of Salvadora persica inhibit the activities
of Steptococcus mutans reducing the development of tooth decay, while extracts from Azadirachta
indica and Acacia nilotica demonstrate antimicrobial activity against Streptococcus mutans. SP was
also effective against anaerobes implicated in periodontal diseases, and their tannin content reduced
clinically visible gingivitis. The sap from Jatropha curcas was very useful in treating oral ulcers, herpes infection aside from candidal infection and toothache. Applications of chewing sticks and/or
their products in managing oral infections could compare with established hospital oral care protocol used in modern health care.
Keywords: Antimicrobial activity, chewing sticks, salvadora persica, caries, periodontal diseases,
oral health
24.1 Introduction
24.1.1
Background
The spate of oral infections and their attendant consequences cannot be overemphasized,
so there is need for global action to address them using effective and affordable products. Typically, infections are caused by microorganisms so managed by antimicrobial
*Corresponding author: ezi.akaji@unn.edu.ng
Durgesh Nandini Chauhan, Prabhu Raj Singh, Kamal Shah, and Nagendra Singh Chauhan (eds.)
Natural Oral Care in Dental Therapy, (383–392) © 2020 Scrivener Publishing LLC
383
384 Natural Oral Care in Dental Therapy
agents, but the indiscreet use of these antimicrobials calls for a revisit of the role of natural products in health care, the basis being that formulations of contemporary drugs
used in today’s world are naturally derived [1, 2]. Hence, an understanding of natural
devices such as chewing sticks, which in time past fostered good oral hygiene, and are still
relevant in the present dispensation, is apt. The support received from the World Health
Organization on alternate practices for oral hygiene with special reference to chewing
sticks, together with the Consensus Report on Oral Hygiene in 2000 constituted a framework for further researches [3, 4]. Aside from these, chewing stick as an oral hygiene tool
properly situates one of the fundamentals of primary health care, that is, “appropriate
technology” serving as substitute for modern manual toothbrush in accomplishing the
goal of prevention of oral diseases via tooth cleaning especially in resource-poor countries where availability and affordability of toothbrushes pose a challenge [5].
24.1.2
Historical Perspectives
The use of these sticks from plants dates back to prehistoric times by the early Arabs,
Babylonian, Greek, and Roman societies. History records that a certain type of chewing
stick for oral hygiene was promoted centuries ago by the Prophet Muhammad and upheld
by some Muslims till date [6]. Also, toothpicks made from sticks were used to clean the
mouth in ancient times, and many communities in developing countries still prefer natural
methods of tooth cleaning over the conventional toothbrushes for their oral hygiene [7].
Chewing sticks, though used, in almost all continents of the world, are more common in
the Middle East, African, and Asian communities (Table 24.1).
24.1.3
Sources and Types of Chewing Sticks
Chewing sticks can be obtained from different types of plants. They include Salvadora,
Acacia, Azadirachta, Terminalia, Ficus, Zanthoxylum, Butea, Pterocarpus, Pongamia, and
Aegle. The common ones are Salvadora persica (SP), Acacia nicolitica (AN) and Azadirachta
indica (AI) [8, 9]. The fresh young stem branches of SP are used to prepare miswak (an
Arabic word for tooth cleaning stick), also known as meswak, miswaki, siwak, siwaki
depending on the dialect [9, 10]. Miswak is used in most continents of the world, and in
places where SP is absent as in West Africa, miswak is obtained from other sources such as
citrus trees [3]. Being derived from plants, these sticks contain bioactive agents with fewer
side effects than the conventional antimicrobial agents [1]. Table 24.1 summarizes the plant
sources of common chewing sticks and their local names where they are found or applied.
24.2 Applications of Chewing Sticks in Oral Health Care
24.2.1
Chewing Sticks for Oral Hygiene
The cleaning stick is washed and chewed at one end until it is frayed. The frayed end
is then used like a “brush” to clean the teeth, gums, and tongue. The inclination of the
bristles to the long axis of the teeth is an advantage for cleaning the surfaces especially
the facial surfaces using a two- or five-finger grip [3]. One or two teeth are cleaned at
Table 24.1 Some common chewing sticks and their local names.
Common name
Local name/language
Part(s) used/remarks
Reference(s)
Salvadora persica
(Salvadoraceae)
Tooth brush tree
Tooth brush tree of Orient
Persian tooth brush tree’
Miswak/Arabic
Datun/India & Pakistan
Miswaki/Tanzania
Root, stem, twigs or bark
Wu et al., 2001 [3]
Sagar, 2015 [9]
Haque and Alsareii, 2015
[11]
Azadirachta indica
(Meliaceae)
Neem, Nimtree, Magosa tree
and Indian Lilac
Datun/India*
Dogonyaro/Hausa
Stem/branches
Sagar, 2015 [9]
Acacia nilotica (Fabacaea)
Indian gum Arabic tree
Babul, Babool, Kikar/
Indian
Twigs
Sagar, 2015 [9]
Idi odan; Pako pupa/
Yoruba
Roots
Flora of West Tropical
Africa extending to
East Africa
Ndukwe et al., 2005 [1]
Rotimi and Mosadomi,
1987 [12]
Terminalia glaucescens/
(Combretaceae)
Fagara zanthoxyloides
(Rutacaea)
Synonym: Zanthoxylum
Zanthoxyloides
Senegal prickly-ash
Candle wood
Orin Ata/Yoruba
Roots
Widely distributed in
African countries
Rotimi and Mosadomi,
1987 [12]
Distemonanthus
benthamianus
(Caesalpiniaceae)
African or yellow satinwood
Orin Ayan/Yoruba
Root and stem
Widely but sparsely
distributed
throughout the high
forests of West Africa
Rotimi and Mosadomi,
1987 [12];
Aderinokun et al., 1999
[13]
Massularia accuminata
(Rubiacaea)
Chewing stick tree
Maiden breast tree
Pako Ijebu/Yoruba
Atu uhie/Igbo
Stem
Rotimi and Mosadomi,
1987 [12]; Aderinokun
et al., 1999 [13]
385
(Continued)
Applications of Chewing Stick in Oral Health
Plant/source
Plant/source
Common name
Anogeissus leiocarpus
(Combretacaea)
Local name/language
Part(s) used/remarks
Reference(s)
Pako dudu/Yoruba
Root
Rotimi and Mosadomi,
1987 [12]
Vernonia amygdalina
(Asteracaea)
Bitter leaf
Ewuro/Yoruba
Onugbu/Igbo
Root and stem
Rotimi and Mosadomi,
1987 [12]
Garcinia kola (GK)
(Clusiacaea)
Bitter kola
Orogbo/Yoruba
Stems and twigs
Ndukwe et al., 2005 [1]
Gboyin Gboyin/Yoruba
Stem and fruit
Ndukwe et al., 2005 [1]
Botuje, Lapalapa/Yoruba
Sap
Agbelusi et al., 2007 [14]
Cnesti ferugenea
(Connaraecaea)
Jatropha curcas
(Euphorbiaceae)
American Purging tree/Big
purge tree
*Datun of Neem, also referred to as “village pharmacy” in India; Yoruba, Igbo, and Hausa are languages spoken in Nigeria.
386 Natural Oral Care in Dental Therapy
Table 24.1 Some common chewing sticks and their local names. (Continued)
Applications of Chewing Stick in Oral Health
387
Figure 24.1 Neem sticks and leaves.
a time with the chewed bristles moving in perpendicular or parallel direction on the
tooth surfaces. Cleaning motion should be directed away from the gum margins but
should stimulate the gums and clean the tongue gently but conscientiously. It is advised
that cleaning be done at least twice a day, morning and night [1]. An advantage of the
use of a chewing stick is the length of time it is used, an average time of 5 to 10 min [1,
15]. Proper use of chewing sticks promote oral cleanliness and removal of plaque, a soft
tenacious material, which develops naturally on the tooth surface, primarily implicated
in dental and periodontal infections. In addition, the chewing stick from the toothbrush tree (miswak) is uniquely suited for brushing teeth because of the synergistic
effect of silica and natural antiseptics found in the sap. Silica has an abrasive potential
so help remove stains, cleaning the teeth the same way baking soda or manufactured
toothpaste does [9]. Extracts especially those from SP (toothbrush tree) and AI (neem
tree) have been used to prepare oral hygiene boosters like toothpaste and toothpowders
and various herbal mouthwashes [6, 9].
24.2.2
24.2.2.1
Ethnopharmacological Applications of Chewing Sticks in Oral Health
Dental Caries (Tooth Decay)
Caries occurs from demineralization and destruction of the tooth structure through the
actions of oral microorganisms, mainly Streptococcus mutans and lactobacilli species. These
bacteria act on the fermentable carbohydrates in the mouth to cause a drop in plaque pH
388 Natural Oral Care in Dental Therapy
to <5.5, and dissolution of the tooth structures ensues [16]. Constituents of chewing sticks
such as fluoride, salvadorine, tannins, anthraquinones, silica, trimethylamine, and essential
oils reduce plaque formation and bacterial growth in the oral cavity [8, 9, 11]. Specifically,
the trimethylamine and salvadorine contents of SP inhibit the activities of Steptococcus
mutans thereby reducing the development of tooth decay. In a compendium culled from
different studies, miswak was found very effective against the initiation and propagation of
dental caries by various researchers [17]. In addition, an in vitro study using extracts from
neem and babool showed that both extracts had antimicrobial activity against Streptococcus
mutans, but the activity was significantly higher in aqueous extract of neem [18]. Also,
aqueous extracts from Rhus vulgaris and Lantana trifolia, which are common chewing
sticks used in Uganda, showed antibacterial activity against S. mutans comparable to benzyl penicillin effects [19].
In addition to silica, chewing sticks such as Garcina kola (GK), Fagara zanthoxyloides (FZ), and SP are rich in fluoride. The anticariogenic actions of fluoride are demonstrated via specific mechanisms: it reduces the solubility of enamel in acid by converting
hydroxyapatite into less soluble fluoro-hydroxyapatite/fluorapatite; exerts an influence
Table 24.2 Key constituents of chewing sticks and their functions.
Constituents
Functions
Fluoride
Gets incorporated into tooth structure and aids caries prevention
Tannin
Acts largely on the oral mucous membrane; inhibits the action of
glucosyltransferase, an enzyme which catalyzes a process in dental
plaque formation hence reducing plaque and inflammation of the
gums
Resins
Serves a physical function by forming a layer over the enamel which
protects it from microbial action
Alkaloids
Perform bactericidal action in the mouth
Essential (volatile) oils
Exhibits anticariogenic action by stimulating salivary flow so
cleansing and maintaining optimum pH in the mouth
Sulfur compounds
Kill bacteria
Vitamin C
This is an antioxidant, thus, slows down oxidative processes in the
body and helps in healing and tissue repair
Sodium bicarbonate
Has mild abrasive and germicidal properties; could be used as
dentifrice
Chloride
In high concentration, chloride inhibits calculus formation and
helps to remove extrinsic stains on the teeth
Calcium
Supports the process of re-mineralization of the tooth enamel
Silica
Performs an abrasive function by removing stains and deposits from
tooth surface
Applications of Chewing Stick in Oral Health
389
directly on dental plaque by reducing the ability of plaque organisms to produce acid, and
promotes the remineralization or repair of tooth enamel in areas that have been demineralized by acids. A study on fluoride content of chewing sticks noted that Zanthoxylum
zanthoxyloides (synonym of FZ) had a mean concentration of 1845 ppm fluoride,
which is slightly higher than the average 1500 ppm fluoride content found in standard
dentifrices [20].
The functions of key constituents of chewing sticks [8, 17] that help maintain good oral
health are in Table 24.2.
24.2.2.2
Periodontal Disease
Periodontal disease is an oral inflammatory disease caused by specific periodontal
pathogens inhabiting periodontal pockets and is characterized by destruction of the
attachment apparatus of the teeth [21]. It is a chronic reaction of gingival tissues in
response to microorganisms associated with dental plaque accumulation; hence, to
control periodontal disease, plaque, which is composed mainly of bacteria, needs to be
removed. Chewing sticks have antibacterial agents, anti-inflammatory, abrasive qualities, and significantly plaque-inhibiting properties. Miswak, for instance, contains tannins, which reduced clinically visible gingivitis and antibacterial agents against a large
spectrum of microorganisms including anaerobes implicated in periodontal diseases
[9, 11]. A much older study observed that four species of anaerobic bacteria implicated
in periodontitis were susceptible to extracts from nine regular tooth-cleaning sticks.
The bactericidal activities against these anaerobes were attributed to the presence of
tannins found at the bark of these chewing sticks. The astringent property of tannic
acid on the oral mucous membrane helps in its antiplaque and anti-inflammatory
activities [12]. Another study demonstrated that the aqueous extracts from most of the
10 cleaning sticks tested, had anti-microbial actions against various microorganisms
that cause diseases; specifically, extracts from sticks derived from Vernonia amygdalina (bitter leaf), Massularia accuminata, and FZ showed significant activities against
periopathogenic bacteria [22]. Hence, proper use of these chewing sticks could aid in
the control of periodontal infections.
24.2.2.3
Oral Candidiasis
This is a fungal infection appearing as soft friable and creamy colored plaques on the
oral mucosa. Candida albicans is the most commonly implicated organism; however,
other candida species like krusei, glabrata, tropicalis, and parapsilosis may be associated
[23]. A study was done to determine the microbiological activity of Fagara zanthoxyloides, Anogeissus leiocarpus, and Distemonanthus benthamianus on clinical isolates of
candida species; all species investigated were susceptible to extracts from the three
tooth-cleaning sticks showing varying but significant inhibition zones [24]. Salvadora
persica can also be used to check candidiasis because of its tannin and alkaloid (salvadorine) components, which are active against fungi [11]. Many African and Indian
plants used for chewing stick exhibit antifungal (possibly from their sulfur content)
and astringent properties, so they can offer great benefits in oral candidal infection
390 Natural Oral Care in Dental Therapy
[8, 17]. The viscid sap from Jatropha curcas (JC) was found very useful in treating
oral ulcers aside from candidal infection and toothache [14]. It can be postulated that
oral lesions such as candidiasis commonly seen in immuno-compromised individuals
would be alleviated with chewing stick extracts.
24.2.2.4
Oral Ulcers and Halitosis
Ulceration is defined as a break in the continuity of an epithelial lining. It usually presents
with pain and discomfort posing some difficulty in eating and drinking. The basic principles of treatment of ulcer are reduction of pain and inflammation, prevention of secondary
infections, and reduction in duration and repetition especially in cases like aphthous ulcer
[23]. The anti-inflammatory, analgesic, and astringent properties, together with their vitamin C content especially in SP and AI and JC, can soothe the discomfort from oral ulcers
and promote healing [8, 9, 14].
An unpleasant odor from the mouth is called halitosis, also called oral malodor or bad
breath. The origin can be from the mouth (intra-oral) or from outside (extra-oral). A wide
range of bacteria are involved in intra-oral halitosis. Hence, one method to reasonably control bad breath is by the use of antiseptic mouth washes/rinses [25]. Natural antiseptics
in Salvadora persica kill the bacteria that cause halitosis and mouth ulcers, just like storebought mouthwash. Astringent and antiseptic properties of neem oil and other essential
oils prevent bad breath by destroying implicated microorganisms. Also, neem leaves can be
used in mouthwash preparations; although bitter (especially to the new users), the individual adapts to the taste with time [9].
24.2.2.5
Other Oral Conditions
Chewing sticks help mitigate dentine hypersensitivity [26]. The desensitizing action could
be due to the astringent properties of chewing stick extracts. Astringents contracts body tissues and canals including dentinal tubules by forming a covering layer over the tubules likened to the action of strontium chloride, thus, reducing the ability of the nerves to transmit
pain as a result of the formed layer. Furthermore, there could also be respite from herpes
infection, spontaneous bleeding from the mouth [14], sore throat [27, 28], and neoplastic
influences [6, 11] through activities of alkaloids (salvadorine), flavonoids, and other antioxidant contents of chewing sticks. Therapeutic efficacy of Salvadora persica in an in vivo
and in vitro study in mice illustrated some benefits in the treatment of recurrent oral herpes
infections. Replication of Herpes simplex virus type 1 on the mice’s skin was inhibited by
SP extracts; this result was attributed to the action of benzylisothiocyanate isolated from
SP [29].
24.3 Conclusions
Inferences about the healing power of plant materials such as chewing stick serving primarily as an oral hygiene tool abound in literature; most have been investigated and substantiated scientifically. Chewing sticks materials or products were observed to offer enormous
benefits in managing oral infections and other conditions. Their applications could compare
Applications of Chewing Stick in Oral Health
391
with those of the established hospital oral care protocol of mouth rinses and drugs used in
modern health care.
References
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2. Douglas, K., Ethnobotanical Medicinal Plants Used as Chewing Sticks among the Kenyan
Communities. BJPR, 13, 1, 1–8, 2016, Article no.BJPR.28833.
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4. WHO, Consensus statement on oral hygiene. Int. Dent. J., 50, 139, 2000.
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8. Hooda, A., Rathee, M., Singh, J., Chewing Sticks In The Era Of Toothbrush: A Review. Internet
J. Fam. Pract., 9, 2, 2009.
9. Sagar, S., Role of natural toothbrushes in containing oral microbial flora—A review. Asian J.
Pharm. Clin. Res., 8, 4, 29–33, 2015.
10. Sukkarwalla, A., Ali, S.M., Lundberg, P., Tarwin, F., Efficacy of Miswak on Oral Pathogens.
Dent. Res. J. (Isfahan), 10, 3, 314–20, May–Jun 2013.
11. Haque, M.A. and Alsareii, S.A., A review of the therapeutic effects of using miswak (Salvadora
Persica) on oral health. Saudi Med. J., 36, 5, 530–43, 2015.
12. Rotimi, V.O. and Mosadomi, H.A., The effect of crude extracts of nine African chewing sticks
on oral anaerobes. J. Med. Microbiol., 23, 55–60, 1987.
13. Aderinokun, G.A., Lawoyin, J.O., Onyeaso, C.O., Effect of two common Nigerian chewing
sticks on gingival health and oral hygiene. Odontostomatol. Trop., 22, 13–8, 1999.
14. Agbelusi, G.A., Odukoya, O.A., Otegbeye, A.F., In vitro Screening of Chewing Stick
Extracts and Sap on Oral Pathogens: Immune Compromised Infections. Biotechnology,
6, 97–100, 2007.
15. Ezoddini-Ardakani, M., Shadkam, M.N., Fotouhi, H. et al., Study of the effects of natural toothbrush (Salvadora persica) in prevention of dental caries and plaque index. Health, 4, 09, 612–8,
2012.
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92S, 2003. Retrieved from https://academic.oup.com/ajcn/article-abstract/78/4/881S/4690063,
12 December 2018.
17. Halawany, H.S., A review on miswak (Salvadora persica) and its effect on various aspects of oral
health. Saudi Dent. J., 24, 2, 63–9, April 2012.
18. Sharma, A., Sankhla, B., Parkar, S.M., Hongal, S., Thanveer, K., Ajithkrishnan, C.G., Effect of
Traditionally Used Neem and Babool Chewing Stick (Datun) on Streptococcus Mutans: An
In-Vitro Study. J. Clin. Diagn. Res., 8, 7, ZC15–ZC17, 2014.
19. Odongo, C.O., Musisi, N.L., Waako, P., Obua, C., Chewing-Stick Practices Using Plants with
Anti-Streptococcal Activity in a Ugandan Rural Community. Front. Pharmacol., 2, 13, 2011.
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20. Taiwo, J.O., Oladipupo, M.M., Denloye, O.O., Assessment of fluoride content of selected chewing stick used in Nigeria. Int. J. Public Health Dent., 3, 2, 1–8, 2012.
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Biotechnol. Biotechnol. Equip., 27, 3, 3754–9, 2013.
22. Taiwo, O., Xu, H.X., Lee, S.F., Antibacterial activities of extracts from Nigerian chewing sticks.
Phytother. Res., 13, 8, 675–9, 1999.
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Sticks on Clinical Isolates of Candida Species. J. Microbiol. Res., 2, 1, 1–5, 2012.
25. Akaji, E.A., Folaranmi, N., Ashiwaju, M.O., Halitosis: A Review of literature on Prevalence,
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26. Odukoya, O.A., Inya-Agha, S.I., Segun, F.I., Agbelusi, G.A., Sofidiya, M.O., Astringency as
Antisensitivity Marker of Some Nigerian Chewing Sticks. J. Med. Sci., 7, 121–5, 2007.
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Health Problems in Cameroon. Evid. Based Complement. Alternat. Med., 10 pages, 2015, Article
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Among the Esan Tribe of Edo State, Nigeria. Ethnobot. Leaflets, 13, 548–63, 2009.
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25
Ethnomedicine and Ethnopharmacology
for Dental Diseases in Indochina
Viroj Wiwanitkit1,2,3,4
*
1
Dr DY Patil University, Pune, India
Faculty of Medicine, University of Nis, Serbia
3
Joseph Ayobabalola University, Nigeria
4
Hainan Medical University, Haikou, China
2
Abstract
Ethnomedicine and ethnopharmacology are important alternative and complementary medicine
systems for the management of health problems. Using ethnomedicine and ethnopharmacology for
dental disease management is very interesting. In an area with a long local history, there are usually
many interesting local ethnomedicine and ethnopharmacology practices. Here, the authors discuss
the ethnomedicine and ethnopharmacology for dental diseases in Indochina, a tropical region in
Asia. In this area, several interesting ethnomedicine and ethnopharmacology practices are observable and considered valuable local wisdoms that are merit for further systematic study.
Keywords: Ethnomedicine, ethnopharmacology, dental, disease, Indochina
25.1 Introduction
For a medical disorder, there are several factors that can affect the clinical presentation and
clinical management. Of several factors, the effect of culture on disease manifestation and
management is an interesting issue. The effect of culture on the dental disease presentation
is widely mentioned and becomes an interesting issue for further investigation. The culturebounded health practice is usually observed in an area with rooted culture and
belief. Indochina, a tropical region in Asia has plenty of local cultures, and some culture-bounded health practices are deeply rooted and widely practiced. Those health
practices are aimed at not only medial but also dental problem management. Some practices are proven useful and accepted as a valuable naturopathy approach. Examples are
the practiced based on locally derived natural medical products such as herbal plants
and medicinal animals.
Ethnomedicine and ethnopharmacology are important alternative and complementary medicine systems for the management of health as well as dental problems.
Email: wviroj@yahoo.com
Durgesh Nandini Chauhan, Prabhu Raj Singh, Kamal Shah, and Nagendra Singh Chauhan (eds.)
Natural Oral Care in Dental Therapy, (393–406) © 2020 Scrivener Publishing LLC
393
394 Natural Oral Care in Dental Therapy
Using ethnomedicine and ethnopharmacology for dental health management is very
interesting. In an area with a long local history, many interesting local ethnomedicine
and ethnopharmacology practices are observable. Here, the authors discuss the ethnomedicine and ethnopharmacology for dental diseases in Indochina, a tropical region
in Asia.
In this area, several interesting ethnomedicine and ethnopharmacology practices considered valuable local wisdoms that merit further systematic studies. The specific interesting ethnomedicine and ethnopharmacology for dental diseases in Indochina are hereby
summarized and presented.
25.2 Ethnomedicine and Ethnopharmacology in Indochina
As already mentioned, ethnomedicine and ethnopharmacology are common health manipulation techniques seen worldwide. Both ethnomedicine and ethnopharmacology are considered culture-bounded practices. By definition, ethnomedicine is health manipulation
based on locally available traditional medicine techniques practiced by local ethnic groups
in each specific setting, and the practice is especially by indigenous peoples [1, 2]. For ethnopharmacology, it is a specific type of pharmacology based on locally available traditional
drug regimens according to the local ethnomedicine [1, 2]. Hence, the background of both
ethnomedicine and ethnopharmacology is specific to the setting. It might be said that both
ethnomedicine and ethnopharmacology are place-specific phenomenon.
There is no doubt that the pattern of ethnomedicine and ethnopharmacology might be
different in different settings (Figure 25.1). Also, in each setting, the ethnomedicine and
ethnopharmacology practice might vary. To understand the specific ethnomedicine and
Local culture, belief
and religious practice
Local naturopathy
and wisdom
Ethnomedicine and
ethnopharmacology
Natural products
resource such as herb
Figure 25.1 Conceptual framework explaining ethnomedicine and ethnopharmacology (graphic drawn by
Wiwanitkit, 2018).
Ethnomedicine and Ethnopharmacology in Indochina
395
ethnopharmacology systems, the practitioner has to have a good knowledge background on
medicine, pharmacology, and sociology. The effect of culture on ethnomedicine and ethnopharmacology in each specific setting is well clarified. As previously mentioned, the format
of ethnomedicine and ethnopharmacology in each setting is considered a culture-bounded
practice, hence, there must be consideration on the local culture when the practice uses or
studies ethnomedicine and ethnopharmacology.
Focusing on Indochina, it is a specific area in tropical Southeast Asia. There are
many countries in the Indochina area including Thailand, Vietnam, Cambodia, Laos,
and Myanmar. This area is one of the old settlements of local people in Asia for many
centuries. There are many ancient legends, cultures, and architectures in Indochina.
Several valuable local wisdoms are observable in Indochina. The local health wisdoms can also be seen. Good examples are several local traditional medicine systems
(Table 25.1).
Table 25.1 Some important local traditional medicine systems in Indochina.
System
Details
Thai traditional medicine or Ayurvej
Thai traditional medicine or Ayurvej is the specific
traditional medicine system seen in Thailand.
The system has been continuously practiced in
Thailand for many centuries. The system has directly
relationship to the Ayurveda in India. The important
health manipulations in Ayurvej include Thai herbal
regimen, Thai message, Thai herbal spa, and Thai
acupressure.
Khmer medicine
Thai traditional medicine or Ayurvej is the specific
traditional medicine system seen in Thailand.
The system has been continuously practiced in
Thailand for many centuries. The system has directly
relationship to the Ayurveda in India. The important
health manipulations in Ayurvej include Thai herbal
regimen, Thai message, Thai herbal spa, and Thai
acupressure.
Vietnamese traditional medicine
Vietnamese traditional medicine refers to the
traditional medicine in Vietnam. The practice is
directly adopted from Chinese traditional medicine.
The most important health manipulation in
Vietnamese traditional medicine is Vietnamese
herbal regimen.
Dongrek medicine
Dongrek medicine is the specific traditional medicine
seen at the border area between Thailand and
Cambodia. This specific traditional medicine system
is the hybrid between Khmer medicine and Thai
traditional medicine [3].
396 Natural Oral Care in Dental Therapy
25.3 Locally Available Naturally Derived Dental Products
in Indochina
A dental product is an important product. There are many kinds of dental products. In different areas of the world, there are also some specific interesting local dental products that
are unique. The locally available naturally derived dental products in Indochina are very
interesting. The first common product is the herbal formula toothpaste. In fact, toothpaste
is a common dental product that everybody uses in tooth brushing process. Many locally
produced toothpastes in Indochina are made from locally available materials including local
herbal plants. Good examples are long-term available toothpastes in Thailand and Laos,
) and Dokbuakooor twin lotus (in Thai word
namely, Wisesniyom (in Thai word
). Focusing on Wisesniyom, it is still produced in classical powder form toothpaste
for direct rubbing at the teeth. Regarding Dokbuakoo, it is more advanced and developed
into modern toothpaste cream form. Regarding Dokbuakoo, there is a scientific study on its
efficacy. Vajrabhaya et al. performed a comparative study to observe changes in the permeability and morphology of dentine surfaces after brushing with this Thai herbal toothpaste
[4]. Vajrabhaya et al. compared Dokbuakoo with a commercial desensitizing toothpaste
and found no difference [4].
In addition to toothpaste, there are also locally available herbal mouthwash solutions.
In fact, an interesting rooted traditional practice of the local people in Indochina is the use
of salted water as mouthwash solution. The locally available mouthwash solutions usually
contain salt and local herb as important ingredients.
The way that a local naturally derived dental product is produced by the local company
is interesting. Many local producers use only a simple technique such as grinding to crush
the herbal plants into herbal powder and further use it to produce toothpaste powder. Some
producers use the ground local herb powder to mix into the toothpaste crease directly to
formulate a modern looked toothpaste dental product. The aim of adding herbal composition is also for attracting the local people who are attached to the concept of naturopathy,
using natural product for health care, including dental care.
An interesting point is the quality control of the standards of the locally available
local herbal dental product. Many products are locally produced and registered as registered local products, but they usually lack medical scientific guarantee for effectiveness and safety. Only a few products passed the standard pharmaceutical study before
manufacturing and marketing. At present, the promotion of local herbal product can
be seen in some Indochina countries such as Vietnam and Thailand. In Thailand, a
specific governmental department for alternative medicine, Thai Department of
Alternative Medicine, is set, and there are some specific universities providing degree
and performing researches on natural herbal products. Regarding herbal dental product, the well-known standardized certified product in Thailand is produced by a specific
local hospital with, namely, Apaipubate brand. An example of an important product
is Apaiphubate mouthwash, which is a modernized formulation with fluoride solution and finger root (Boesenbergia rotunda L.) extract. Similarly, there is also another
important product, Apaiphubate toothpaste, which is a modernized herbal toothpaste with composition of finger root. Regarding finger use, a scientific study shows
Ethnomedicine and Ethnopharmacology in Indochina
397
that this herb has antibactericidal activity, which might be useful for dental health
promotion [5].
Comparing the price of those products to the generally available dental products, the
price of the herbal dental product is slightly more expensive. Those locally herbal dental products are considered registered local products and already certified by the public
health body. The standardization by the laboratory of the Thai Department of Alternative
Medicine is available.
25.4 Ethnopharmacology for Dental Diseases in Indochina
Ethnopharmacology is deeply rooted in Indochina. The use of ethnopharmacology for the
management of dental diseases can be seen in several forms. The important forms will be
hereby discussed.
A. Herbal regimen
The herbal regimen is the common alternative drug commonly used in Indochina. Many
herbal products in Indochina are also ethnologically used for dental management. As previously mentioned in this chapter, the famous local herb claimed for the advantage on dental health is finger root. Finger root is used as an important composition in many locally
manufactured dental products. The main effect of finger root is the antibactericidal activity,
which is useful for the control of oral bacteria. The β-lactam-resistant staphylococci can be
well managed by the finger root extract [5].
Another important herb is mangosteen (Garcinia mangostana L.), which is a tropical
fruit seen in Indochina. There are some locally available herbal regimens made from mangosteen extracts. The effect of the extract on management of gum disease is mentioned. In
a study by Rassameemasmaung et al., the effect of herbal mouthwash with important gradients of the pericarp extract of Garcinia mangostana L on plaque, papillary bleeding index,
and halitosis is studied [6]. The effectiveness of the mangosteen extract for the management
of gingivitis can be observed [6]. Rassameemasmaung et al. concluded that “Herbal mouthwash containing the pericarp extract of G. mangostana may be used as an adjunct in treating
oral malodor [6].”
Apart from the herbs that have anti-bacterial activity, some local herbs are also
mentioned for its activity against fungus. The lemongrass (Cymbopogon citratus) is another
important locally available herb in Indochina. This herb is proven for its fungicidal activity [7]. Amornvit et al. found that lemongrass essential oil could effectively kill Candida
albicans [7]. The control of oral thrust or oral candidiasis is possible using lemongrass
essential oil.
Another interesting herb is Siamese rough bush (Streblus asper) or Koi [8]. This is a
locally well-known medicinal plant in Indochina [8]. The lead extract of Siamese rough
bush has antibacterial activity [9]. The high antioxidative activity of this herb is also
reported [10]. Due to this property, Siamese rough brush has an advantage in the control of
dental plaque [11]. Wongkham et al. studied this herb and proposed that the herb could be
further developed into an anti-caries drug [10]. Indeed, the bark of this herb is also widely
398 Natural Oral Care in Dental Therapy
used by local ethnic people in Indochina for tooth brushing. The tree is also known as tooth
brushing tree.
B. Animal product regimen
Many animals products in Indochina are also ethnologically used for dental management.
A good example is the shell of Tegillarca granosa, which is a tropical mollusk. This seashell has been used by the local people for the preparation of toothpaste. According to
the local wisdom, the shell is burnt to get the ash for further use as toothpaste. Another
important animal product is cuttlebone, which is a kind of marine skeleton. The cuttlebone
is mentioned for its usefulness for the promotion of dental strength. It is also classified
as an important marine drug composition. Local ethnic in the coastal areas of Thailand,
Laos, and Cambodia has used cuttlebone as a composition in their locally produced toothpaste powder for a very long time. Scientifically, cuttlebone is proven useful in hard tissue repair and regeneration; hence, it might be useful for the case of dental erosion or
caries [12].
C. Mineral product regimen
Many local minerals in Indochina have been long term known to be used by local people
for the management of oral health. Maine salt has been used for the preparation of mouthwash by the local people. In the remote landlocked area such as in the northern region of
Thailand and Laos, the local ethnic people can use the available dirt salt for preparing a similar mouthwash. Regarding the effectiveness of saltwater solution, Aravinth et al. compared
salt water rinse with chlorhexidine against oral microbes and found that “Salt water rinse
can be used as adjunct to routine mechanical plaque control for prevention of oral diseases
[13].” Hence, the use of salt for the preparation of salt mouthwash is an actual local wisdom
of local ethnic people in Indochina for dental health management.
Dental organ
Animal
product
Herb
Mineral product
Figure 25.2 Ethnopharmacology in Indochina (Hand drawing and photograph by Wiwanitkit, 2018).
Ethnomedicine and Ethnopharmacology in Indochina
399
Apart from the single herb, there are also many ethnological compound herbal regimens
that are mentioned for their usefulness in the management of oral problems in Indochina.
For example, “Manee” is a local herbal compound formula that is ethnologically used by
the local people for the promotion of good dental health. Considering the formula, Manee
consists of several local natural products including Tegillarca granosa shell, Siamese rough
bush, Mimusopselengi, clove (Syzygium aromaticum), guava, mint, Pterocarpus santalinus,
alum, marine salt, lemon, ebony (Diospyros rhodocalyx Kurz), cuttlebone, and Borneol
camphor (Dryobalanops aromatica). The Manee compound is mentioned for its usefulness
in the management of several oral problems including apthous ulcer, oral malodor, dental
caries, and toothache.
If we classify by oral disease, the important ethnopharmacology for each specific group
of oral problem will be further detailed.
A. Oral malodor
As already mentioned, mangosteen is the tropical fruit that is proven for its usefulness
in the control of unwanted oral odor [6]. In additional to mangosteen, the local people
in Indochina also use guava (Psidium guajava L) extract for the control of mouth smell.
Guava has high flavonoids and high vitamin C. Also, there is a report that guava has antibactericidal activity [14]. Shetty et al. recently studied the efficacy of guava extract as an
antimicrobial agent on periodontal pathogens and found that the extract was effective
against Porphyromonas gingivalis and Aggregatibacter actinomycetemcomitans [14]. The
control of oral malodor is generally due to the antibactericidal activity of the ethnopharmacological regimen.
Nevertheless, an important preventive method against oral malodor is the good dental
care by tooth brushing and oral washing. The already mentioned locally available dental
products, herbal toothpaste, and mouthwash, are also good ethnopharmacological natural
products for the prevention of oral malodor problems.
B. Gingivitis
Gingivitis is the specific inflammation of the gums, and this is a common problem around
the world.
As previously mentioned, the mangosteen extract is an effective ethnopharmacological regimen for the management of gingivitis [6]. Another ethnopharmacological regimen
against gingivitis is Wildbetal Leaf bush (Piper sarmentosum). This regimen has been widely
used in Thailand, Cambodia, and Laos. Nevertheless, there is still no scientific proof on its
usefulness in the management of gingivitis. Indeed, there are also other ethnopharmacological regimens that are mentioned for their usefulness in the management of periodontal
disease. The important ones are listed in Table 25.2.
C. Oral thrush
Oral thrush is a common orodental problem. Candidiasis is an important infection causing oral thrush. As already mentioned, lemongrass essential oil is a famous local ethnopharmacological regimen for the management of oral thrush by the local ethnic people in
Indochina [7].
400 Natural Oral Care in Dental Therapy
Table 25.2 Some important ethnopharmacological regimens that are mentioned for usefulness in
management of periodontal disease.
Regimens
Details
Galanga (Alpinia galanga)
This is a single herbal regimen. For usage, local
ethnical people will use fresh peeled galanga
crushed with salt for direct chewing.
Indian gooseberry (Phyllanthus emblica)
This is a single herbal regimen. Indian gooseberry is
a local tropical fruit in Indochina. For usage, local
ethnical people will use the heat water extract of
equal amount of Indian gooseberry for drinking
in the early morning.
White butterfly pea (Clitoria ternatea)
This is a single herbal regimen. Butterfly pea is a
local tropical flower in Indochina. The ethnic
people in northern region of Thailand and Shan
state of Myanmar regularly use the alcoholic
(liquor) extract of white butterfly pea for
management of gingivitis.
D. Toothache
Barleria cristata is an important herbal regimen that is widely used by the local people in
Indochina for the management of toothache. As already mentioned, the traditional alternative medicine system gets a lot of effects from the Indian Ayurveda. A similar use of this
Table 25.3 Some important ethnopharmacological regimens that are mentioned for usefulness in
management of toothache.
Regimens
Details
Galanga
This is a single herbal regimen. For usage, similar
way that local ethnical people use for management
of gingivitis in is described.
Tea
Tea is the well-known plant that its leaf is used
for preparation of tea beverage Tea drinking in
common in Vietnam. The tea is also mentioned
for its usefulness against toothache. It is
traditionally as ethnopharmacological regimen for
relief of toothache among East Asian ethnic [16].
Aloe vera
This is a single herbal regimen. Aloe vera is a locally
available herb that is well-known for its usefulness
in burn wound healing. The aloe vera is also
mentioned for its usefulness against toothache.
Similar to the use in Brazila in South America
[17], the aloe vera regimen is also an important
ethnopharmacological regimen for management
of toothache.
Ethnomedicine and Ethnopharmacology in Indochina
401
herbal regimen as described for the management of toothache in the Indian Ayurveda can
be seen in Indochina [15]. Indeed, there are also other ethnopharmacological regimens that
are mentioned for their usefulness in the management of toothache. The important ones are
listed in Table 25.3.
E. Dental caries
Some local ethnopharmacological regimens in Indochina are mentioned for their usefulness in the management of caries. Good examples are cuttlebone regimen [12] and Siamese
rough bush [10].
Wiwattanarattanabut et al. recently studied several Thai culinary herbs for their anti-cariogenic plaque effects [17]. In that in vitro study, Wiwattanarattanabut et al. evaluated essential oils extracted from sweet basil (Ocimum basilicum), cinnamon bark (Cinnamomum
zeylanicum), sweet fennel (Foeniculum vulgare), kaffir lime (Citrus hystrix), black pepper (Piper nigrum), peppermint (Mentha piperita), and spearmint (Mentha spicata) and
found that cinnamon and sweet basil essential oils have acceptable in vitro anti-cariogenic bacteria and anti-plaque effects [18]. Joycharat et al. recently studied antibacterial
substances from Albizia myriophylla wood, a common ethnopharmacological Thai herb,
against cariogenic pathogens and found that the wood is effective in inhibiting the pathogen [19]. Based on the described evidence, there are several local herbs in Indochina that
are reported for their activities and usefulness against dental caries. Conclusively, the promotion of tissue strength and the antibacterial activities of the local ethnopharmacological regimens are the main possible mechanisms against dental caries. Further in depth
researches on the ethnopharmacological regimens that have potentials against dental rabies
are recommended.
F. Bleeding gum
Bleeding gum is a common orodental problem. Bleeding gum is usually due to vitamin
C deficiency. Several local ethnic people in Indochina know and usually use guava, tammarind, and citrus fruits that have high vitamin C content for the management of the problem. Intake of those natural products can help not only in the management of orodental
problems but also prevents the problems. The high vitamin C in several locally available
ethnopharmacological regimens, which are also tropical citrus fruits, is the main preventive factor against bleeding gums. Nevertheless, the simple use of saltwater solution for
regular mouth washing by local people is also proven useful in the prevention of bleeding
gums [13].
In some rare cases, bleeding gums might be the result of a system medical problem.
For example, in Indochina, where the tropical mosquito-borne infectious disease is common, dengue might be the cause of bleeding gums. The patient with dengue might first
present with bleeding gums [20]. The problem is directly due to the thrombocytopenia
due to the illness. The use of ethnopharmacological regimen against bleeding gums due
to dengue is very interesting. Papaya extract is reported for its usefulness in the management of bleeding gums and other bleeding disorders in cases with dengue [21]. For
the pharmacological mechanism, the papaya leaf extract has antithrombocytopenic
and immunomodulatory effects that can counteract the immunopathological process
that results in thrombocytopenia and bleeding complications, including bleeding gums
in dengue [22].
402 Natural Oral Care in Dental Therapy
25.5 Ethnomedicine for Dental Diseases in Indochina
As already mentioned, ethnomedicine practice is not uncommon in Indochina. There are
many interesting ethnomedicine practices for dental management. The important ones will
be further mentioned.
A. Ethnodrug
As already mentioned earlier in this chapter, there are many available ethnopharmacological regimens for the management of dental problems in Indochina. There are several available ethnodrugs. Many ethnodrugs are still ritual drugs or locally prepared herbal drugs
that still need improvement in their pharmaceutical process. Focusing on standard produced ethnodrug by modern pharmaceutical process, there are some available regimens.
In Thailand, a famous regimen named Fahtalayjones is registered and included in the
national drug list as a modern herbal regimen that is allowed for use in the modern standard medical center. The regimen is made from the ethno drug regimen from of the herb
named Andrographis paniculata. An important indication of Fahtalayjones is for the relief
of toothache.
B. Ethnodental procedure
Ethnodental procedure is an interesting issue in traditional and alternative dentistry. In
fact, several dentistry procedures have been performed for many centuries. The local
methods for dental extraction by the local ethnic groups are interesting. The use of
a local herb for the relief of pain during extraction is common. A good example is the
use of aloe vera regimen. It is also reported that aloe vera also helps in promoting healing after dental extraction [23]. In additional to herbal regimen, some traditional alternative medicine practices are also applicable in helping relieve toothache. A good example
is the use of acupuncture technique among the Chinese ethnics. Also, the construction
of artificial tooth by a local classical technique is also observable in Indochina [24]. The
practice is commonly seen among Chinese ethnic Indochina, and the classical tooth insertion service is usually available in China towns. Artificial tooth insertion by the classical
technique is still observed at present, and some local people use this technique due to its
inexpensive cost.
In additional to dental extraction, dental fixation by ethnodental procedure is also observable in Indochina. In fact, due to the historical evidence appearing at the old Cambodian
temple, it is evidenced that dental fixation technique might have already existed in the
past millennium in Indochina [25]. The picture of orthodontic braces at the ancient temple reflects the long-lasting wisdom on dental procedure among the local people in
Indochina [25].
C. Ethnodental cosmetics
Ethnodental cosmetics is an interesting issue. The local culture-related style of dengue fashion becomes an important dental variant seen around the world. In Indochina, the fashion
on betel nut chewing has ever been deeply rooted. At present, betel nut chewing is still
common in Myanmar [26]. The black tooth is the previous dental fashion in Indochina. In
the past, several local people in Indochina chewed betel nut aiming to have beautiful black
Ethnomedicine and Ethnopharmacology in Indochina
403
Figure 25.3 Golden teeth procedure, an ethnocosmetics in Indochina (Photograph taken by Wiwanitkit,
2018).
teeth [27]. In some remote areas of Indochina, some tribers have specific interesting ethnodental cosmetics belief and might perform interesting dental procedures such as cutting
teeth aiming at a strange shape.
Nevertheless, the specific more common ethnodental cosmetic practice seen in several
cities in Indochina is the golden teeth procedure (Figure 25.3). This is a tooth manipulation
by covering of the teeth with gold. This ethnodental cosmetic practice is developed from
classical artificial tooth insertion procedure. Nevertheless, the additional ethnodental cosmetic procedure such as diamond implantation to the incisor is also observed among some
rich ethnic people in Indochina.
25.6 Future Trend of Ethnomedicine and Ethnopharmacology
for Dental Diseases in Indochina
At present, there are still many ethnomedicine and ethnopharmacology systems for dental
diseases in Indochina. Those practices are presently commonly used in several areas in this
area. Those practiced are expected to still remain for a very long time in the future. With
the merging new trend on the use of natural products and naturopathy, there will be many
new researches and developments regarding the locally existing ethnomedicine and ethnopharmacology for dental diseases in Indochina. The development of research technologies
and methodologies for better assessment of ethnomedicine and ethnopharmacology will be
widely done. New modern products based on the existing ethnomedicine and ethnopharmacology for dental diseases in Indochina are expected to be successfully developed and
continuously launched in the near future.
With the trend in increased interest on ethnomedicine and ethnopharmacology for
dental diseases in Indochina, there is a requirement for good control. The future trend of
increased importance of quality control on pharmaceutical processes of ethnopharmacological products is expected. Quality accreditation and standardization are the coming general
basic requirements. There will be the setting of a new health agency for specific responsibility regarding ethnomedicine and ethnopharmacology. Finally, the ethical control on the
404 Natural Oral Care in Dental Therapy
practice will be another emerging important issue for dental practice relating to the use of
ethnomedicine and ethnopharmacology in Indochina.
25.7 Conclusion
Many ethnomedicine and ethnopharmacology systems for dental diseases in Indochina are
very specific. Those practices can reflect the specific cultural and geographical background
in Indochina. The proven advantages of many ethnomedicines and ethnopharmacology
for dental diseases in Indochina can confirm the merit of those local health management
wisdoms. There is merit in focusing on research and development regarding ethnomedicine and ethnopharmacology for dental diseases in Indochina aiming to find new modern
developed formulations that will be effective in the management of the important dental
problems.
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26
Traditional Medicinal Plants Used in Anti-Halitosis
P. Shivakumar Singh1*, Pindi Pavan Kumar2 and Dasaiah Srinivasulu2
1
Department of Botany, Palamuru University, Mahabubnagar, Telangana State, India
Department of Microbiology, Palamuru University, Mahabubnagar, Telangana State, India
2
Abstract
Halitosis is an oral health condition characterized by unpleasant odors emanating constantly from
the oral cavity. Almost 22–50% of the population experiences such a condition during lifespan,
and about half of them suffer from personal discomfort and social embarrassment. The intrinsic
causes of halitosis are both oral cavity and systemic disorder. In the current report, a total of 34
traditional medicinal plants used against halitosis from the Palmuru district of Telangana state,
India, were documented. In this study, 34 natural plants species belonging to 29 genera and 19
families were found. The leading families like Anacardiaceae have four species followed by each
of the three species from Annonaceae, Arecaceae, Moraceae, Cucurbitaceae, whereas two of each
species were found in six families. The remaining nine families showed single species. Previous
studies revealed that some of these plants have shown biological activities relating to anti-halitosis
effect. The present study revealed the existence of indigenous knowledge of medicinal plants to
treat halitosis.
Keywords: Traditional medicinal plants, halitosis, oral cavity, Anacardiaceae
26.1 Introduction
In the usual manner and in typical circumstances, a mouthful of air is odor-free, and the
mouth ought to not have a scent. Normally, obviously, the mouth of a person has a meticulous stink called human smell, i.e., halitosis [1]. Halitosis is an unpleasant or offensive odor
emanating from the oral cavity regardless of its origin. It is common in people of all ages
with the prevalence of 22% to more than 50% [2–4]. Decomposition of proteins, mucin, and
peptides by microbes of the tongue and dental plaque as well as anaerobic gram-negative
bacteria can create unstable sulfur composites that are accountable for the awful odor [5].
Halitosis is a major pathologic constituent for periodontal and oral mucosa. There are
400 concerning microorganisms in the mouth [6]. The foul smell that is released from the
mouth can be resulting from the oral hollow.
*Corresponding author: shivakumarsinghp@gmail.com
Durgesh Nandini Chauhan, Prabhu Raj Singh, Kamal Shah, and Nagendra Singh Chauhan (eds.)
Natural Oral Care in Dental Therapy, (407–414) © 2020 Scrivener Publishing LLC
407
408 Natural Oral Care in Dental Therapy
The reasons of oral malodor are abridged by ultimately the mouth, but the breath smell is
not diminished by non-oral causes [7]. Mouth odor amended during the diverse days, level
throughout dissimilar period of a day are diverge, and the quantity of mouth odor depends
on the stream rate of saliva, food remains, accretion, and production of bacteria and conceivably metabolic alters [8, 9].
The World Health Organization (WHO) in 1978 has estimated that 80% of the populations of developing countries rely on traditional medicines, mostly plant drugs, for their
primary health care needs. The use of traditional medicines and medicinal plants in most
developing countries as therapeutic agents for the maintenance of good health has been
widely observed [10]. In India, 65% of the population relies on ethnomedicine, which is
the only source of their primary health care needs. India is one of the 12 mega-biodiversity
countries of the world having rich vegetation with a wide variety of plants with medicinal
value. Over 550 tribal communities are covered under 227 ethnic groups residing in about
5000 villages in India in different forests and vegetation types [11]. In many countries, scientific investigations of medicinal plants have been initiated because of their contribution
to healthcare. It is also necessary to collect information about the knowledge of traditional
medicines, preserved in tribal and rural communities of various parts of India before it is
lost permanently. Recently, various ethno botanical studies have been reported to expose
the knowledge from the various tribals of India. Documenting the indigenous knowledge
through ethno botanical studies is important for the conservation of biological resources
as well as their sustainable utilization. In such a way, the aim of the present study is to document the ethno medicinal plants and practices followed for oral health and diseases and
to suggest that the traditional knowledge should be integrated with modern dental care
practices to formulate their sustainable utilization [12].
26.2 Materials and Methods
Customary field trips were commenced in diverse localities of the study area throughout the
period from May 2015 to June 2017. Localities were selected in such a way that they would
correspond to the entire mandal counting rural areas and tribal pockets. The catalog of the
traditional practitioners on the diverse areas was equipped. During the fieldwork, recurrent
visits were completed by the herbal practitioners, and they were induced to reveal their traditional information about the curative plants. The in sequence about the foliage was evidenced
by means of deliberations and meetings using standard questionnaire [13] with the informers,
and the length of the pasture visits during compilation hours. The in sequence was teetered
like local names of the plant, parts used, and methods of groundwork. The information concerning the components, added techniques of management or request, quantity and period of
prescription, and connected medicated foodstuff were also recorded in a few events.
The composed plant specimens were genuinely recognized with the help of flora such as
Flora of Telangana Vol. I, II & III [14], Flora of British India, and Flora of Gulbarga District
[15], and the voucher numbers were specified, and herbarium specimens were equipped.
The people of the study area can talk four languages. The plant assortment is extremely
affluent, and a good quality number of medicinal plants are used in the healing of a variety
of illnesses including mouth discomforts. Consequently, the current study proved the rural
knowledge on medicinal plants used against halitosis.
Traditional Medicinal Plants Used in Anti-Halitosis 409
26.3 Results and Discussion
The current report reveals the natural plants and their therapy for halitosis, revealing an
immense sum of 34 natural plants used in the precise study area of Mahabubnagar district,
Telangana state, India. A certification has been approved using a customary questioner.
The study showed that 34 natural plants species belonging to 29 genera and 19 families
were found valuable. The leading family was the Anacardiaceae with four species followed
by each of the three species from Annonaceae, Arecaceae, Moraceae, and Cucurbitaceae,
whereas two species were found in six families. The remaining nine families showed single
species. The present report explained them thoroughly along with the habit, local name,
botanical name, family, and therapeutic property. The medicinal plants used in anti halitosis were predicted (Table 26.1). The habitat, the part used graphically, is represented in
figure forms (Figure 26.1, Figure 26.2, Figure 26.3, Figure 26.4). The backdrop of the therapeutic plants is shown in the figures.
Oral rinses or mouthwashes are also effective products in preventing mouth bad odor.
Mouthwashes, which have alcohol, make the mouth dry and worsen the problem. The plant
remedies, such as black and green teas, due to having polyphenols, can reduce the sulfur
compounds and decrease oral bacteria [16]. The plants presented in the present chapter
are also rich in polyphenols. In most of the cases, polyphenols also performs antimicrobial
Table 26.1 Traditional medicinal plants used in anti halitosis.
Sl. no
Botanical name
Family
Local name
Habit
Part used as anti
halitosis
24
Semecarpus
anacardium
Anacardiaceae
Nallajeedi
Tree
Root
25
Sicca acida
Euphorbiaceae
Rachausiri
Tree
Leaves
26
Solanum anguivi
Solanaceae
Mulla
vankaya
Herb
Flower
27
Solanum nigrum
Solanaceae
Kamanchi
Herb
Fruit
28
Syzygium cuminii
Myrtaceae
Neradu
Tree
Seed powder
29
Tamarindus indica
Caesalpiniaceae
Chinta
Tree
Fruit, flower, leaves
30
Terminalia
bellerica
Combretaceae
Tani
Tree
Bark, fruit
31
Terminalia chebula
Combretaceae
Karakaya
Tree
Bark, fruit
32
Vitis heyneana
Vitaceae
Adavi
draksha
Climber
Leaves
33
Zizyphus
mauritiana
Rhamnaceae
Pedda regu
Tree
Fruit, seed powder
34
Zizyphus jujuba
Rhamnaceae
Regu
Tree
Fruit, seed powder
(Continued)
410 Natural Oral Care in Dental Therapy
Table 26.1 Traditional medicinal plants used in anti halitosis.
Sl. no
Botanical name
Family
Local name
Habit
Part used as anti
halitosis
1
Aegle marmelos
Rutaceae
Maredu
Tree
Fruit pulp & Seed
2
Alangium
salvifolium
Alangiaceae
Uduga
Tree
Ripened fruit &
Seed powder
3
Anacardium
occidentale
Anacardiaceae
Jeedimamidi
Tree
Unripe fruit and
root powder
4
Anana sqomosus
Bromiliaceae
Anasa
Shrub
Flower
5
Annona muricata
Annonaceae
Lakshmana
phalum
Tree
Terminal buds
6
Annona reticulata
Annonaceae
Ramaphalum
Tree
Seed powder
7
Borassus flabellifer
Arecaceae
Tati
Tree
Seed juice
8
Buchanania
lanzan
Anacardiaceae
Sarapappu
Tree
Leaf juice
9
Cucurbita maxima
Cucurbitaceae
Gummadi
Climber
Seeds
10
Coccinia grandis
Cucurbitaceae
Thonda
Climber
Unripe fruit
11
Ficus religiosa
Moraceae
Ravi
Tree
Terminal buds,
bark and fruits
12
Ficus auriculata
Moraceae
Konda ravi
Tree
Roots
13
Ficus racemsoa
Moraceae
Medi Atti
Tree
Fruits, Bark juice
14
Limonia acidissima
Rutaceae
Velaga
Tree
Fruit pulp
15
Mangif era indica
Anacardiaceae
Mamidi
Tree
Flower
16
Manilkara hexandra
Sapotaceae
Palachettu
Tree
Bark
17
Mimordica dioica
Cucurbitaceae
Agakara
Climber
Climbed stem
18
Opuntia dillenii
Cactaceae
Nagajamudu
Shrub
Fruit
19
Pavonia odorata
Malvaceae
Tigabenda
Herb
Leaves juice
20
Phoenix loureiroi
Arecaceae
Chittietha
Shrub
Leaves juice
21
Phoenix sylvastris
Arecaceae
Etha
Tree
Flower
22
Phyllanthus emblica
Euphorbiaceae
Usiri
Tree
Fruit, bark, root
23
Pithecolobium
dulce
Mimosaceae
Chimachinta
Tree
Flower
Traditional Medicinal Plants Used in Anti-Halitosis 411
Figure 26.1 Study area, Mahabubnagar District, Telangana State, India.
Percentage (%)
Climbers
8%
Herbs
8%
Shrubs
8%
Trees
76%
Figure 26.2 Portion distribution of expansion forms of traditional medicinal plants used in anti halitosis and
their habitat.
Stem
5%
Buds
6%
Root
5%
Fruit
29%
Flower
15%
Seed
15%
Leaves
17%
Bark
8%
Percentage (%)
Figure 26.3 Portion distribution of part of traditional medicinal plants used in anti halitosis.
412 Natural Oral Care in Dental Therapy
Rhamnaceae
Combretaceae
Myrtaceae
Mimosaceae
Malvaceae
Sapotaceae
Cucurbitaceae
Annonaceae
Anacardiaceae
Rutaceae
0
10
20
30
40
50
Figure 26.4 Segment allocation of expansion forms of traditional medicinal plants used in anti halitosis.
activities and improved immune activities [17]. Other plants also contain similar types of
agents [18], and this might be beneficial in resolving this health problem. These types of
plants have a diversity of additional properties [19]. Therapeutic plants can be used for the
treatment of infections [20, 21]. In the present report, the documentation work was done,
whereas the previous report by Plerenpit Yasin et al. [22, 23] showed an antimicrobial activity, which proved the successive prohibiting of halitosis. In the future, studies presenting
the outcome of the reported species should provide the scope to perform the extractions,
isolations, characterizations, and antimicrobial activity.
The present chapter has given evidences for the common plant usage in halitosis. It is an
easy-to-use form and allows access to areas that are difficult to reach. It is practiced after
brushing for the hygiene of the teeth, prevention of pathologies, gingivitis therapy, aesthetics, and well-being against halitosis. The ability of the herbal extract, in mouthwashes to
reduce gingival inflammation and plaque formation and to be used as an irrigation agent to
disinfect the root canal with less toxicity, has been well documented.
26.4 Conclusion
Halitosis is a disagreeable odor emitted while some people are talking or inhaling, which
can be a symbol of universal oral disorders. This can be controlled using the above-reported
medicinal plants and their products. The present chapter demonstrates that plant molecules and extracts could be developed into products, which could be used by the common
man to treat oral infections. Whereas the fluoride-based toothpaste and brushes results in
Traditional Medicinal Plants Used in Anti-Halitosis 413
damage to the mouth tissue in adults, plant-based toothpaste gives positive results in curing
halitosis.
Furthermore, the current documented information on the medicinal plants of the
Mahabubnagar district people can be used as baseline data for future studies of pharmacologically important medicinal plants and for phytochemical investigations.
Acknowledgment
The authors are thankful to the rural, folkloric, an ethnic people of the precise study area
of Mahabubnagar district of Telangana state for their participation on innate therapeutics.
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Index
3,4,5-trihydroxybenzoic acid, 231
A. actinomycetemcomitans, 244, 252, 253
Acacia arabica, 32, 34, 38
Actinidin, 153, 154, 163
Actions of triphala, 300
Active constituent identified from coconut, 278
Agar well diffusion assay, 83, 87, 88
Alkaloids, 133
Allergy, 165
Allicin, 346–348, 351, 354–357, 359, 362
Alliin, 347, 348, 351
Alliinase, 348, 351
Aloe vera, 32, 33, 37, 62, 63, 65–67, 69, 74, 99,
100, 400
anti-inflammatory activity, 106
anti-inflammatory mechanisms, 100
citotoxicity, 105, 106
for Gingivitis and Periodontitis, 100
other oral applications, 100
Alpha Tocopherol, 62, 72, 73
Amalaki, 298, 299
Analgesic, 316
Analgesic and antipyretic action, 307
Animal, 398
Anti-cancer action, 307
Anti-candida effect, 301
Anti-collagenase action, 301
Anti-diabetic action, 307
Anti-gingivitis, 319, 320
Anti-inflammatory action, 307
Anti-microbial activity, 300
Anti-oxidant action, 300
Anti-plaque, 319, 320, 323
Antibacterial, 111–113, 115, 117, 121, 122, 127,
129, 241, 242, 244, 250, 251, 313–317,
320, 321
Antibiotic resistance, 346, 352, 353, 362
Antibiotics, 154, 156
Cefadroxil, 87, 88, 91
Erythromycine, 87, 88, 91
Tetracycline, 87, 88, 91
Anti-cancer, 156, 317, 321
Anti-candidiasis, 321
Anticaries, 321
Anticariogenic - activity-compound, 83–86, 88,
89, 91, 93, 94
Anti-erosive agent, 241, 242
Antifungal, 314, 318, 322
Anti-inflammatory, 45, 46, 49–54, 144, 145, 148,
236, 241, 252, 314–316, 318, 319
Antimalarial, 315, 318
Antimicrobial, 45–47, 52, 54, 111–113, 115,
117, 121, 122, 127–129, 143, 144, 147, 148,
313, 317–323
Antimicrobial-action -activity, 84, 85, 87, 88,
91, 94
Anti-neoplastic, 315
Antinociceptive, 316
Antioxidant, 48–54, 61, 64–66, 70, 72, 73,
143–145, 317, 319, 321
Antioxidant activity, 231, 236, 239, 244, 252, 253
Antiplaque, 3
Antiplaque effect, 243, 244
Anti-pyorrhea effect, 335
Antipyretic, 314
Antiradical, 315
Anti-thrush effect, 335
Anti-ulcer, 144, 145, 314
Antiviral, 317
Anti-xerostomia effect, 334
Artemisia, 34, 38
Astringency, 230, 236, 241, 244
Attributes of chewing sticks,
anti-bacterial, 388, 389
anti-cariogenic, 388
anti-inflammatory, 389, 390
oral hygiene, 383, 384, 387, 390
415
416 Index
Avulsed tooth, 165
Ayurveda, 141, 142
Ayurvedic, 61, 62, 69
Ayurvedic medicine, 133
Azadirachta indica, 33–35, 313, 314, 316,
319, 321
Azadirachtin, 313, 315, 317
Baccharis dracunculifolia, 211, 214
Bauhinia,
Bauhinia forficata link, 111, 112, 119
Bees, 211, 222
Beta carotene, 61–64, 71
Betamethasone, 66
Bibhitaki, 298, 299
Bioactive compounds, 83, 85, 92
Bioautography, 83, 88, 93
Biocompatibility, 240, 248, 250
Biofilm,
dental biofilm, 121, 122, 127–129, 211, 217,
219, 220, 222
Biological properties,
antibacterial, 211, 214, 216–218
anticancer, 211, 218, 221
antifungal, 211, 218–220
anti-inflammatory, 211, 214, 220, 221
antimicrobial, 215–217, 221
antioxidant, 211, 215, 221
Biomimetic approach, 245–247, 251
Biomodifier, 242, 245
Black pepper, 68
Bonding, 249
Bowman–Birk inhibitor concentrate, 73
Burning mouth, 146, 149
Calendula, 37
Cancer, 154, 156, 157
Candida, 158
Candida albicans, 133
Candidiasis, 134
Cardamom,
Elettaria cardamomum, 121, 122
Caries, 176–178, 216, 222, 401
Cariogenic bacteria - Staphylococus aureus Lactobacillus acidophilus - Streptococcus
mutans - Lactobacillus casei -Actinomyces
viscosus, 83–85, 88, 91, 92, 94
Cariology, 240, 241
Catechin, 230–232
Cellulose membranes, membrane disk, 121,
125, 126, 128, 129
Chamomile, 35, 36
Charcoal production methods, 199
Chemical classification of natural oral care, 14
alcohol, 15
aldehyde , 15
alkaloids, 14
amino acids, 15
enzymes, 15
flavones, 14
flavonoids, 14
flavonols, 14
glycoside, 15
ketones, 15
lectins, 15
organosulfur compound , 15
phenolic acids, 14
phenols, 14
quinone dervatives, 15
saponins, 14
terpenes, 14
terpenoid, 14
Chemical constituents, 286
Chemical constituents of Ocimum Sanctum,
260–262
Chewing sticks sources and types,
acacia nicolitica, 383–385
azadiratcha indica, 383, 385
distemonanthus benthamianus, 385, 389
fagara zanthoxyloides, 385, 388, 389
garcinia kola, 386, 388
jatropha curcas, 386, 389
massularia accuminata, 385, 389
miswak, toothbrush tree, 384, 385, 387 – 389
neem, 385–390
salvadora persica, 383, 385, 387, 389
vernonia amygdalina, 386, 389
Children, 122, 124, 126, 128
Chinese herbs, 62, 73
Chlorhexidine, 300–306
Chlorhexidine, chlorhexidine digluconate, 111,
113–116, 121, 122, 124–126, 128, 217, 220
Chymotrypsin, 157
Cinnamon, 37
Classification of natural oral care, 5
analgesic, 5
antiadhesion activity, 6
antianxiety, 5
Index 417
anti-halitosis, 6
antiplaque, 5, 6
local anesthetic, 5
natural antioxidant, 9
pulpal and dentin repair, 8
root canal irrigation, 7
sealer cements, 9
solvents, 9
storage medium, 8, 9
whitening agent, 5
Clobetasol, 68
Clove, 32, 33
Coagulation, 156
Coconut oil, 32
Colchicine, 62, 66
Collagen, 159, 162
Condensed tannins, 230, 233, 237, 243
Confocal laser scanning microscopy (CSLM),
247
Constituents,
astringent, 389, 390
extracts, 387, 389, 390
fluoride, 388, 389
resins, 383, 388
salvadorine, 383, 388–390
sap, 383, 387, 389, 390
silica, 383, 387, 388
sulfur compounds, 388, 389
tannins, 383, 388, 389
vitamin c, 388, 390
CPP-ACP, 242
Cross-linking agent, 229, 237, 241, 248, 250
Curative plants worn in the healing of mouth
evils, 373–383
Curcumin, 49, 50, 61, 65, 68, 72, 73, 75
Cysteine proteases, 154, 164, 170
Cytoprotective, 241, 253, 254
Cytotoxic potential, 111, 114, 115, 118
Dalbergia,
Dalbergia ecastophyllum, 211, 214
Dalbergia odorifera, 214
Dental abscesses, 352
Dental biofilm, 111, 112, 114–118
Dental caries, 32, 33, 37, 38, 83, 84, 91, 95, 121,
122, 128, 141, 145–148, 345, 346, 352, 354,
356–358
Dental caries, carious lesion, 111, 112
Dental plaque, 33–37, 243, 244
Dental plaque - biofilms, 84
Dentifrice, 163, 164
Dentistry, 3, 211, 221, 222
Desensitization, 236
Designer, 234
Diabetes mellitus, 134
Diterpenoids, 316
Divine tree, 314
Dry bonding, 249
Ecchymosis, 155, 166
Echinacea, 36, 37
Edema, 154, 155, 166
Emblica, 34, 38
Emblica officinalis, 297–299
Endodontic irrigants, 250, 253
Endodontics, 320
Endodontitis, 345, 354, 356
Enterococcus, 158
Enterococus faecalis, 245, 250
Epicatechin, 230–233, 235
Epigallocatechin, 70, 71
Essential oils, 133
Ethano-botanical, 85
Ethanol, 111–114, 116–118, 122, 213–217, 219
Ethnomedicine, 394
Ethnopharmacology, 394
Eucalyptus, 35
Ex vivo, 118, 121, 124
Exemplary potential of coconut water in
dentistry, 275
Extract, 112, 122–124, 127, 215–217, 221
Extraction, 154, 155, 165, 166
Extraction, isolation, identification of chemical
constituents, 287
Fatty acids, 145, 147
Fibrinolysis, 156
Ficin, 153, 154, 164
Flavonoids, 133, 211, 213–215, 217, 219–221,
229, 230, 239
Formocresol, 356, 359
Galanga, 400
Gallic acids, 230, 231
Gedunin, 315
Gel permeation chromatography, 234, 236
Gingival bleeding, 145, 146
Gingival region, 84
418 Index
Gingivitis, 45, 48, 50–53, 55, 98, 141, 147, 148, 163,
164, 299, 301, 303, 304, 306, 319, 323, 399
Glucosyltransferases, 236, 237, 243
Gram-negative, 83, 84, 94
Gram-positive, 83, 94
Grape seed extracts, GSEs,
chemical structure, 230
components, 230
methods of separation, 233
types, 231
Grapes, 229, 233–235
Green tea, 32, 34, 38, 48, 49, 62, 70, 71
Gum, 401
Halitosis, 34, 141, 142, 146–149, 164, 185, 186,
204, 354, 355, 360
Haritaki, 298, 299
Healing effect in root canal therapy, 334
Herbal formulation, 85
Herbal medicine, 133
High-performance liquid chromatography,
HPLC, 230, 231, 234
History of Ocimum Sanctum, 260
Honey, 54–55
Human gingival fibroblasts, 102
anti-inflammatory activity in a Gingivitis
model, 103
authorization, 102
cell culture, 102
cell subculture, 102
citotoxicity test, 103
statical Analysis, 103
HUVEC cells, 254
Hyaluronidase, 64–66, 68, 70
Hydrastis canadensis, 37
Hydrocortisone, 64–66
Hydrogen bonding, 238
Hydrophobic effects, 236
Hydrophobicity, 84
Hypersensitivity, 165
Hypoglycemic, 314, 323
Immunomodulatory action , 308
In vitro, 112, 116, 118, 129
Indochina, 394
Inflammation, 100
Interleukin, 252
Intra-lesional, 62–70
Itraconazole, 135
Lactobacillus, 158
Licorice, 37, 39
Limitations of natural oral care, 16
Local drug delivery, 319
Lozenges, 68
Lycopene, 61, 62, 64, 65, 72, 74
Macleya cordata, 35
Mahmoodin, 315
Malodor, 399
Mangifera indica, 34
Mango, 34, 46, 47, 51
Matrix metalloproteinase, 252
Medicinal plant, 97
Melaleuca alternifolia, 33, 35
Meswak, 32
Microhardness, 160
Microleakage, 159–161
Microorganisms, oral microorganisms,
112, 113, 116, 117
Actinomyces naeslundii, 217
C. glabrata, 219
C. krusei, 219
Campylobacter jejuni, Campylobacter coli, 127
Candida albicans, C. albicans, 122, 127, 219
Enterococcus spp., Enterococcus faecalis, 217
Klebsiella spp., 217
Lactobacillus casei, L. casei, 121, 123,
127, 128
planktonic cells, 112, 118, 129
Saccharomyces cerevisiae, 127
Staphylococcus aureus, 217
Streptococcus mutans, S. mutans, 111–118,
121–123, 127, 128, 216, 217, 220
Streptococcus sanguinis, 216
Streptococcus sobrinus, 217
Miswak, 47
Modulus of elasticity, 249
Molecular recognition, 236
Mouth deodorizing effect, 336
Mouth rinse, 301
Mucositis, 154, 156, 157
Myrrh, 35, 36
NaOCl, 250, 251
Neem, 33–35, 47, 51, 313–323
Nigella, 62, 68
Nimbidin, 313, 314, 316
Nimbolide, 314, 315, 317, 321
Index 419
Novel drug delivery formulations,
nanofibers, 264, 265
nanoparticles of biocompatible
Ocimum sanctum-coated silver
nanoparticles, 264, 265
β-Cyclodextrin Ccomplexes, 264, 265
Ocimum, 62, 68
Oil,
coconut oil, 144, 145, 147–149
corn oil, 144
oil pulling, 141–150
palm oil, 144
rice bran oil, 144
sesame Oil, 141, 143, 144, 147–150
soya bean oil, 144
sunflower oil, 141, 143, 144, 147
Oil pulling, 34
Oral antibiofilm, 111
Oral biofilm,
actinomyces, 177
aggregatibacter actinomycetemcomitans, 174
candida albicans, 174
lactobacillus, 177
porphyromonas gingivalis, 174
streptococcus mutans, 177
streptococcus sobrinus, 177
tannerella forsythia, 174
treponema denticola, 174
Oral cancer, 3, 45, 71, 72, 154, 222, 254, 356, 360
Oral candidiasis, 183, 184
Oral cavity, 83–85, 94
Oral disease, 83, 85, 91
Oral fibroblasts, 111, 117, 118
Oral flora, 84
Oral health, 141, 146
Oral hygiene, 84, 141, 149
Oral malodor, 141, 149
Oral microbiome, 172–175
Oral thrush, 149
Organic solvents, 83
Orthognathic surgery, 155, 166
Osteoarthritis, 157
OTC dental care products, 198
Other significance of coconut, 276
commercial usage of husk fibers, 278
convention of coconut roots, 278
economic importance of coconut stem, 278
economic value of coconut leaves, 276
importance of coconut shell, 277
potential of coconut fruits, 277
significance of spathe and inflorescence, 277
use of coconut heart, 277
usage of coconut milk, 277
PAHM, 233
PALM, 233
Panaxnoto, 67
Pediatric dentistry, 121, 124, 126, 129
Pellicle, 164
Pentoxyfilline, 67
Peppermint oil, 36
Peri-implantitis, 253
Periodontal, 319, 320
Periodontal disease, 84, 181–183, 301
Periodontitis, 45, 46, 48–52, 54, 55, 98, 99, 319,
323, 345, 346, 353–356
Pharmacological properties of coconut, 273
Pharmacology—therapeutic activity of
Salvadora persica L., 287–292
antibacterial and antifungal, 290
anti-cariogenic effect, 290
antiperiodontitis effect, 291
antiplaque effect, 290
anti-viral effect, 290
theories for Miswak activities, 287
whitening effect, 292
Phenolic, 211, 215–217, 219–221
Phytochemical, 10–15
Phytochemical constituents, 93
Phytotherapy, 211
Pictacia vera, 39
Pinot Gris, 234
Pinot Noir, 234, 235
Piper, 65, 68, 69
Piper betle, 39
Plant, 112, 116, 211, 213, 214
Plaque, 50–53, 55, 84, 91, 300, 301, 303–306,
319, 320
PLGA, 247
PMN, 315
Polyherbal, 62, 68
Polyphenols, 66, 70
biochemical properties, 236
cultivar, 234
factors, 233, 234
methods of separation, 233
physical properties, 235
420 Index
Pomegranate, 32
Populus, 38
Prednisolone, 67
Premalignant, 61–63, 70, 73
Preventive dentistry, 320, 321
Proanthocyanidins, 229, 230, 245, 246, 250
Probiotics, 175
dairy products, 180
lactobacillus, 174
mechanisms of action, 179, 180
mouthwashes, 180
powder, 180, 181
tablets and lozenges, 181
Propolis, 211–223
Proteases, 153, 154, 163, 164
Protection against aphthous stomatitis, 338
Protein-polyphenol interactions, 236–238
Prunella vulgaris, 35
Punica granatum, 134
Punicalagin, 135
Quality of life, 154, 165, 166
Quercus infecteria, 83–87, 91–94
Radix salvia, 67
Redox reactions, 240
Replantation, 165
Role of coconut tree in dental ministrations, 274
Role of triphala in wound healing, 307
Root canal, 320, 323
Root canal irrigant, 300
S mutans, 299, 300
Safety of natural oral care, 15
Sage, 35, 36
Saliva, 84, 121, 122, 124, 126, 128
S-allycysteine, 361
Salvadora persica, 32, 33, 36, 38
Salvia miltiorrhiza, 67
Salvianolic acid, 67
Sanguinaria canadensis, 37
Saponification, 143, 145, 147
Sepsis, 156, 166
Sesame, 48, 52
Smear layer, 160, 162
Sodium hypochlorite, 85, 251
Sodium lauryl sulfate, 122
Spearmint oil, 37
Spirochetes, 83
Spirulina, 62, 65–67
Staphylococcus, 156
Stomatitis, 345, 358
Streptococcus, 158
Streptococcus mutans, 236, 237, 243, 245
Tannins, 133, 315
Tannins, quinones, 298
Tea, 400
Tea pigments, 62, 66
Tea tree, 33, 35
Teeth, 111, 112, 216, 222
Termibalia, 34, 38
Terminalia bellerica, 297–299
Terminalia chebula, 297–299
Therapeutic significance of ocimum in dental
health and preventive care management,
262–264
Therapy, 400
Thin layer chromatography (TLC), 87, 88, 92, 93
Thrush, 399
TMJ/temporomandibular joint, 157
Tooth polishing, 336
Toothache, 84
Toothpaste, 164
Traditional medicinal plants used in antihalitosis, 407–415
Traditional usage and ethnopharmacological
relevance, 272
Trend, 403
Triamcinolone, 66, 67, 74, 75
Triphala formulations, 308
Triphala phytoconstituents, 298, 299
Trismus, 154, 155, 166
Trolox equivalent antioxidant activity (TEAC),
239
Trypsin, 156, 157, 163
Tulsi, 51, 52, 61–63, 68
Turmeric, 46, 49, 50, 61–63, 68, 69, 74,
100, 101
for gingivitis and periodontitis, 101
other oral applications, 101
Ulcerative gingivitis, 84
Utimate tensile strength (UTS), 246
Index 421
Vitamin A, 71, 72
Vitamin C, 72
Vitamin E, 72
Vitis vinifera, 229, 230
Wound debridement, 155
Wound healing, 318
Wet bonding, 249, 250
Whatman filter paper, 85
Zingiberaceae, 121, 122, 127
Xerostomia, 145, 147