Aloe vera: Nature's soothing healer to periodontal disease.

BACKGROUND: Recent interest and advances in the field of alternative medicine has promoted the use of various herbal and natural products for multiple uses in the field of medicine. Aloe vera is one such product exhibiting multiple benefits and has gained considerable importance in clinical research. This clinical study focuses on Aloe vera and highlights its property when used as a medicament in the periodontal pocket.
MATERIALS AND METHODS: A total number of 15 subjects were evaluated for clinical parameters like plaque index, gingival index, probing pocket depth at baseline, followed by scaling and root planing (SRP). Test site comprised of SRP followed by intra-pocket placement of Aloe vera gel, which was compared with the control site in which only SRP was done, and clinical parameters were compared between the two sites at one month and three months from baseline.
RESULTS: Results exhibited encouraging findings in clinical parameters of the role of Aloe vera gel as a drug for local delivery.
CONCLUSION: We conclude that subgingival administration of Aloe vera gel results in improvement of periodontal condition. Aloe vera gel can be used as a local drug delivery system in periodontal pockets.

INTRODUCTION

Periodontitis is an infectious inflammatory disease. Bacteria modulate the inflammatory response and alter the diversity of periodontal disease. In recent years, various host-response modulation therapies and local drug therapies have been developed to block the pathways responsible for periodontal tissue breakdown.[1]

Aloe vera is a cactus plant that belongs to the Liliaceae family. More than 300 species of aloe plants exist, but only 2 species have been studied, which are Aloe barbadensis Miller and Aloe aborescens.[2] Ideal environment to grow this plant is tropical climate and low-rainfall areas.[3]

The Aloe vera leaf consists of 2 different parts: central mucilaginous part and peripheral bundle sheath cells. The parenchymal tissue makes up the inner portion of the aloe leaves and produces a clear, thin tasteless jelly-like material called Aloe vera gel.[4] In recent years, various cosmetic and medical products are made from the mucilaginous tissue present in the center of the Aloe vera leaf in the form of Aloe vera gel.

History

Aloe vera has been used medicinally since the last few thousand years. History states that wars have been fought, as by Hannibal, in order to obtain control over its growing area in North Africa around 1750 BC. Its uses are mentioned in various books and Mesopotanian clay tabloids in various countries like Egypt, Greece,[5] South Africa, India, China, Mexico, Japan[4] for various ailments like burns, hair loss, skin infections, hemorrhoids,[6] sinusitis, gastrointestinal (GI) pain. It is also a wound healer for bruises, x-ray burns,[5] insect bites; and anti-helminthic, somatic, anti-arthritic.[7-18]

Aloe vera is a handy home remedy that can be used as a moisturizing agent.[19] Aloe vera has been used for various skin conditions, including radiodermatitis,[20] frostbite, psoriasis and genital herpes infection with good results.[721] Reported pharmacological actions of Aloe vera include anti-inflammatory,[522-27] antibacterial,[28-33] antioxidant,[34] antiviral[35-37] and antifungal actions,[38] as well as producing hypoglycemic effects.[21]

Dental uses of Aloe vera are multiple.[3940] It is extremely helpful in the treatment of gum diseases like gingivitis, periodontitis.[3] It reduces bleeding, inflammation and swelling of the gums. It is a powerful antiseptic in pockets where normal cleaning is difficult, and its antifungal properties help greatly in the problem of denture stomatitis,[41] apthous ulcers, cracked and split corners of the mouth.[42] It is a powerful healing promoter and can be used following extractions.[43] It has been used in root canal treatment as a sedative dressing and file lubrication during biomechanical preparation.[39]

Various forms of Aloe vera used[333944]

As a toothpaste, mouthwash

As gel for promoting healing in burns, stings, insect bites and many skin lesions; it protects and promotes healing[45]

As Aloe activator topical spray, which is used for throat infections, painful teeth eruptions and joint pains

Aloe vera juice, which is taken systemically as a drink for irritable bowel syndrome and as a strong detoxifying agent. It also acts as neurosedative and an immune enhancer

As powerful nutritional supplement and antioxidant

AIMS AND OBJECTIVES

To evaluate the clinical effects of subgingival application of Aloe vera gel in periodontal pockets of adult periodontitis patients after mechanical debridement.

MATERIALS AND METHODS

Fifteen patients having moderate periodontitis were selected from the OPD of the Department of Periodontics, Jaipur Dental College, Jaipur. The study population comprised of 15 patients (7 females, 8 males) aged 20 to 35 years. The subjects had not received any antibiotics or periodontal treatment in the previous 6 months and had a negative history of any systemic diseases. All participants were provided with information about the study, and an informed consent was obtained. A split mouth design was planned and armamentarium used for the study is depicted in Figure 1. Subjects having minimum one tooth or site in a quadrant (maxilla or mandible each) with probing depth of 5 mm along with bleeding on probing were selected.

Figure 1

Armamentarium used for the study

Clinical procedures

Patients were advised to continue with their routine oral hygiene regime. The following clinical parameters were recorded at baseline, 1 month and 3 months:

Plaque index[46]

Gingival index[47]

Probing pocket depth from the gingival margin to the depth of the pocket using Williams graduated probe.

Immediately after recording all the indices at baseline and prior to drug application, all the patients underwent scaling and root planing with hand instruments. The Aloe vera gel was injected into the pockets with a syringe with blunt needle around the selected teeth in the treatment test sites [Figure 2]. The pockets were filled until the materials were detected at the gingival margin. To ensure that the Aloe vera gel stayed long enough to be effective in the pocket, a periodontal dressing (Coe pak) was placed over the treated sites. The control site [Figure 3] received only scaling and root planing.

Figure 2

Test site Aloe vera gel application

Figure 3

Control site

Statistical analysis

The results were subjected to statistical analysis. The differences in parameters as determined between their baseline, 1-month and 3-month mean values were assessed by using Student t test.

RESULTS

The mean values of various parameters at baseline, 1 month and 3 months are given in Table 1 and Figures 4–6. The results showed improvement in plaque index, which showed a mean difference of 1.78±0.51 with P<0.001 between baseline and 1 month, which was highly significant; and at 3 months, the mean difference was 1.75±0.50 with P<0.001 [Table 2], which was highly significant. Gingival index showed a mean difference of 1.57±0.46 with P<0.001 between baseline and 1 month, which was highly significant; and at 3 months, the mean difference was 1.59±0.40 with P<0.001 [Table 3], which was highly significant. For the pocket depth in the test group, mean difference from baseline value was 0.92 ± 0.09 at 1 month; and at 3 months, it was 1.71±0.81 with P<0.001 [Table 4], which was highly significant. In the control group, mean difference from baseline value was 0.50±0.13 at 1 month; and at 3 months, it was 0.78±0.30 with P<0.001 [Table 5], which was highly significant; but the mean difference between the test and control groups at 1 and 3 months was statistically significant with P<0.01 [Table 6].

Table 1

Mean values of various parameters at baseline, 1 month and 3 months

Figure 4

Mean values of plaque index at various levels

Figure 6

Mean values of pocket depth of test and control groups at various levels

Table 2

Mean change±standard deviation (SD) in plaque index from baseline value to various intervals

Table 3

Mean change±SD in gingival index from baseline value to various intervals

Table 4

Mean change±SD in pocket depth from baseline value to various intervals (test)

Table 5

Mean change±SD in pocket depth from baseline value to various intervals (control)

Table 6

Mean difference±SD in pocket depth between test and control groups

Mean values of gingival index at various levels

DISCUSSION

Treatment of periodontal diseases by different types of local delivery systems has been investigated.[48-52] All the subjects attending this study showed statistically significant improvements in clinical parameters at the 1-month and 3-month examinations compared to those at baseline.

Aloe vera applied in test site resulted in significant reduction in pocket depth when compared to controls and reduction in gingival index, which can be attributed to its anti-inflammatory, antibacterial, wound-healing properties. Aloe vera has numerous anti-inflammatory agents. Fujita et al,[53] stated that carboxypeptidase in Aloe vera inactivates bradykinin by about 67% and relieves pain . Rocio Bautsta in 2004[24] showed that carboxypeptidase in Aloe vera had good anti-prostaglandin synthesis properties and compounds inhibiting oxidation of arachidonic acid, which might decrease inflammation. Aloe vera contains salicylate magnesium lactate decarboxylase, which is known to inhibit histidine, thereby preventing the formation of histamine from histidine in mast cells.[54] Heggers and Robson[55] in 1983 showed that barbolin and aloe emodin in aloe vera block prostaglandin (PG) synthesis. The decrease in gingival index can be attributed to presence of sterols as anti-inflammatory agents and lupeol as an antiseptic analgesic. Vazquez et al, stated[22] Aloe vera decreases edema and number of neutrophils and also prevents migration of Poly morpho nuclear leucocytes (PMNL). Barrantes and Guinea in 2003[56] stated Aloe vera inhibits the stimulated granulocyte Matrix metallo proteinases (MMPs) inhibiting cyclo-oxygenase and lipo-oxygenase pathways. Payne,[3] reported Aloe vera gel used in wound site lessened inflammation with less pain. Hart et al,[57] in an in vitro study stated Aloe vera depleted the chemical and alternative pathways of complement activity to inhibit the production of free oxygen radicals by activated Poly morpho nuclear leucocytes (PMNs). Aloe vera is also shown to provide relief in swelling, bleeding gums and is an antiseptic for pockets and antifungal for thrush.[58]

The low plaque index observed in these subjects could be explained by the fact that Aloe vera is a good antibacterial. Hegger et al,[29] showed its antibacterial properties against Candida albicans, Streptococcus pyogens, Streptococcus fecalis. Noskova,[59] used Aloe vera to treat early stages of periodontitis and got good results.

The study exhibited significant decrease in pocket depth and relative decrease in gingival and plaque indices at 1 month and 3 months, exhibiting good healing, which is in accordance with studies by Davis,[17] who stated that wound healing with Aloe vera was due to increased blood supply; increased oxygenation, which stimulates fibroblast activity; and collagen proliferation. Davis,[16] in in vitro and in vivo studies showed healing with fibroblast proliferation. Wound healing by means of growth factors such as gibberellins, auxin and mannose phosphate, which bind to insulin-like growth factor receptor to improve healing, is also seen. Yagi et al,[9] stated presence of glycoprotein with cell proliferation improves healing. Aloe vera also contains vitamins A, C, E, B 12, folic acid. Vitamin C, which is involved in collagen synthesis, increases concentration of oxygen at the wound site because of dilation of blood vessels. Aloe vera penetrates and dilates capillaries going to an injured site, which improves healing.

Davis et al,[60] showed that healing is better and wound tensile strength is increased after its application on wounds. Choonhakarn et al,[58] used 70% Aloe vera gel for recurrent apthous ulcers and lichen planus, which showed that healing was better and fast. Mandeville in 1939[42] used Aloe vera for the treatment of radiation ulceration of mucous membrane of the mouth. Bovik in 1966[61] used Aloe vera for the gingivectomy sites and showed that healing was better and fast. There was no discomfort, hypersensitivity or abnormal tissue reactions observed in the present study.

CONCLUSION

On the basis of this study, we conclude that subgingival administration of Aloe vera gel results in improvement of periodontal condition. Aloe vera can be used as a local drug delivery system because of its various benefits:

Easily available

Easily applicable with minimal equipments

Cheap

No adverse effects, as shown in our study

The study was a short-term study. Long-term studies are required with larger sample size. More research on its healing properties, antibacterial, anti-inflammatory properties and releasing pattern as a local drug delivery system is required.