Benefits of Aloe vera in dentistry.

Aloe vera (Aloe barbadensis) is a plant that belongs to Liliaceae family. The name Aloe derives from the Arabic word "Alloeh" meaning shining bitter substance while "vera" in Latin means true. It contains various minerals and vitamins. It has got various properties such as immunomodulatory, antiviral and antiinflammatory in nature. A. vera can play a significant role in dentistry in treatment of lichen planus, oral submucous fibrosis, recurrent aphthous stomatitis, alveolar osteitis, periodontitis, etc.

Aloe vera (Aloe barbadensis) is a succulent plant that belongs to Liliaceae family. The name Aloe derives from the Arabic word “Alloeh” meaning shining bitter substance while “vera” in Latin means true. There are more than 300 species of the aloe-plant, but the Aloe barbadensis species exhibits the best medicinal properties. It grows mainly in the dry areas of Africa, Asia, Europe, and America.[1] Ideal environment to grow this plant is a tropical climate and low rainfall areas.

Aloe-plant Description

The outermost layer is a hard rind that is 15 cells thick. This rind is very important because this is where the syntheses of all 75 nutrients that are contained within the plant occurs. Below this lawyer is the sap. This is a circulation system that basically moves materials up to the leaves and down to the roots. The sap is very rich in anthraquinones, which are powerful laxatives.

The mucilage layer basically holds the plant together. It also acts as a barrier and keeps the inner gel very sterile. The mucilage layer is very high in polysaccharides including the immunomodulator, acemannan. The gel that is below this, also known as parenchyma, is where the leaf stores all its nutrients. The gel is fileted out at the mucilage layer. This retains all the sterile gel with its nutrients, the mucilage layer with its valuable polysaccharides and just the right amount of anthraquinones from the sap layer. Too much sap in the final product would increase the laxative effect.

Contents of Aloe vera Gel

Until date, 75 nutrients have been identified in stabilized A. vera gel.

The most important are: Lignin is a cellulose-based substance found in the gel with no known specific medicinal properties although its presence in topical aloe preparations is thought to provide the ability to penetrate the human skin.

Saponins are glycosides which are thought to comprise about 3% of A. vera gel. They are soapy substances, containing antiseptic properties, which are capable of cleansing.

Minerals

Vitamins

Aloe vera contains many vitamins, including Vitamin A, C, E, B1, B2, B3 (niacin), B6, choline, folic acid, alpha-tocopherol, beta-carotene. A. vera is also one of the few plants that contain vitamin B12.

Vitamins A, C and E are important antioxidant vitamins, essential in the fight against damaging free radicals. All three positively influence the immune system and Vitamin C in particular assists in wound healing. It also makes collagen, keeping bones skin and joints firm and strong. Vitamin A is essential to maintain normal night vision. Vitamin E helps the body utilize oxygen, prevents blood clots, thrombosis, and atherosclerosis. It also improves wound healing and fertility.

Antiinflammatories

In addition to vitamins and minerals, [Table 1] A. vera has ingredients that act as antiinflammatories. Bradykinase is an A. vera enzyme, which reduces skin inflammation. A. vera has 12 anthraquinones, also known as laxatives. It has fatty acids, salicylic acid and hormones called auxins and gibberellins, all of which result in inflammation reversal. These anti-inflammatories work most often by stimulating immune system function and collagen growth, or by blocking the paths of irritants.

Table 1

Role of minerals

Amino acids

The human body requires 20 amino acids for good health to be maintained, and all but eight can be manufactured in the body. The others called essential amino acids need to be taken as food. Together they form the building blocks of proteins from which we manufacture and repair muscles.

Aloe vera provides 19 of the 20 required amino acids and seven of the eight essential ones. The missing amino acid is tryptophan, although Bill Coates, an American pharmacist and Aloe expert, claims it has this one too. The evidence is not conclusive yet, although providing seven out of the eight required is good going.

Enzymes

Aloe vera contains many enzymes, which can be divided into two groups, those that aid digestion and those that are anti-inflammatory. Of the ones that aid digestion some, like amylase, break down starch and sugar, while others, such as lipase, help break down fats.

Sugars

Aloe vera contains two sorts of sugars, monosaccharides, such as glucose and fructose, and long chain sugars called polysaccharides, the main one being a glucomannose often referred to as Acemannan.

Acemannan has been shown to have several actions:

Immunomodulating properties – it helps to return immunity to normal by boosting the level of antibodies

Antiviral – particularly against tumor producing viruses, such as feline leukemia

Reduces secondary infections

Increase the activity of T-lymphocytes by up to 50%

Increase the activity of large white blood cells (macrophages) leading to increased wound healing.

Sterols

The plant sterols are important anti-inflammatory agents. Of the three ones, lupeol, acts as an antiseptic and analgesic agent.

Salicylic acid

Also found in A. vera, is metabolized in the body to an aspirin-like compound which, together with lupeol, provide some of its painkilling properties.

Applications in Dentistry

Oral lichen planus

Choonhakarn et al.[2] conducted a randomized controlled trial study to check the efficacy of A. vera gel in the treatment of oral lichen planus (OLP). He concluded that A. vera gel is statistically significantly more effective than placebo in inducing clinical and symptomatological improvement of OLP. Therefore, A. vera gel can be considered a safe alternative treatment for patients with OLP.

Oral submucous fibrosis

Sudarshan et al.[3] carried out a preliminary study to compare the efficacy of A. vera with antioxidants in the treatment of oral submucous fibrosis (OSMF). In this study, 20 subjects with OSMF were included. Patients are divided into two groups, Group A received 5 mg of A. vera gel 3 times daily for 3 months, and Group B received antioxidant capsules twice daily for 3 months. He concluded that A. vera group showed a better treatment response (reduced burning sensation and enhanced mouth opening) than the antioxidants group. Hence, it can be applied topically and effective in the treatment of OSMF.

Recurrent aphthous stomatitis

Babaee et al.[4] conducted a double-blind clinical trial to evaluate the topically administered A. vera gel on oral cavity minor aphthous. It was concluded that A. vera 2% oral gel is not only effective in decreasing the patient's pain score and wound size, but also decreased the aphthous wound healing period.

Radiation-induced oral mucositis

Ahmadi[5] postulated that oral A. vera mouthwash may not only prevent radiation-induced mucositis by its wound healing and antiinflammatory mechanism, but also reduce oral candidiasis of patients undergoing head and neck radiotherapy due to its antifungal and immunomodulatory properties. Hence, A. vera mouthwash is an alternative agent for treating radiation-induced oral mucositis and candidiasis in patients with head and neck cancers.

Gingivitis

Ajmera[6] et al. conducted a study to evaluate the antiinflammatory property of A. vera mouthwash on plaque-induced gingivitis. Forty-five patients who were diagnosed with plaque-induced gingivitis were included in the study. They were divided into three groups with fifteen patients in each group. Group 1 was asked to rinse with 10 ml of A. vera mouthwash twice daily for 3 months. Group 2 were treated with scaling only. Group 3 patients were asked to rinse with A. vera mouthwash and scaling was done. The result suggested reduction in gingival inflammation in all the three groups, but it was more reduction in the A. vera mouthwash and scaling group. Davis et al.[7] tested the anti-inflammatory and wound healing activity of A. vera due to the presence of growth substance mannose-6 phosphate. Hence, it was concluded that A. vera had a significant anti-inflammatory property. Thus, it can be used as an adjunct to mechanical therapy for treating plaque-induced gingivitis. Bovik in 1966[8] used A. vera for the gingivectomy sites and showed that healing was better and fast.

Periodontitis

Bhat[9] et al. evaluated the clinical effects of subgingival application of A. vera gel in periodontal pockets of adult periodontitis patients after mechanical debridement. In this study, 15 subjects were evaluated for clinical parameters such as plaque index, gingival index, probing pocket depth at baseline, followed by scaling and root planning (SRP). Test site comprised of SRP, followed by intra-pocket placement of A. 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 1-month and 3 months from baseline. Results exhibited encouraging findings in clinical parameters of the role of A. vera gel as a drug for local delivery and it was concluded that subgingival administration of A. vera gel results in improvement of periodontal condition. A. vera gel can be used as a local drug delivery system in periodontal pockets.

Tooth gel

Aloe vera tooth gel is effective in controlling bacteria that causes cavities than other commercially available toothpaste. A. vera gel's ability to kill and remove harmful microorganisms is due to compounds called anthraquinones, which are antiinflammatory. A. vera gel does not contain the abrasives found in most toothpastes, hence less harsh on teeth and it is a better alternative for people with sensitive teeth.

George et al.[10] conducted an in vitro evaluation regarding the antimicrobial activity of an A. vera tooth gel (forever bright tooth gel) and two commercially popular tooth pastes (Colgate, Palmolive) and concluded that A. vera tooth gel was effective than two commercially popular toothpastes in controlling all the organisms that is, Streptococcus mutans, Candida albicans, Lactobacillus acidophilus, Streptococcus mitis, Enterococcus faecalis, Prevotella intermedia, and Peptostreptococcus anaerobius. In addition, the A. vera gel demonstrated superior antibacterial effect against Streptococcus mitis despite the absence of additional fluoride.[11]

Alveolar osteitis

Poor et al.[12] compared the incidence of alveolar osteitis (AO) in patients treated with either clindamycin-soaked Gelfoam or SaliCept Patches. The SaliCept Patch is a freeze-dried pledget that contains Acemannan Hydrogel (Carrington Laboratories, USA) obtained from the clear inner gel of A. vera. The results suggested that the SaliCept Patch significantly reduced the incidence of AO compared with clindamycin-soaked Gelfoam.

Denture Cleanser and Adhesive

Denture patients with sore ridges and ill-fitting dentures and partials can benefit as fungises and bacterial contamination reduce the inflammatory irritations.[13]

The sticky and viscous nature of acemannan, aprototype acemannan was formulated into a denture adhesive and evaluated for adhesive strength in both wet and dry conditions; the adhesive also was used to evaluate cytotoxicity to human gingival fibroblasts. An optimal formula with a high and relatively stable adhesive bond strength and minimum cytotoxicity was observed.[14]

Dental Implants

Aloe vera can also be used around dental implants to control inflammation from bacteria contamination.[13]

Storage of Gutta Percha Cones

Prakash P Athiban et al.[15] concluded that A. vera is indeed effective as a GP decontaminant and it holds a promising future as a medium for storage of GP cones.

Root Canal Filling Material in Primary Teeth

Kriplani et al.[16] conducted to evaluate the antimicrobial effectiveness of A. vera with sterile water zinc oxide and eugenol, zinc oxide-eugenol (ZOE) with A. vera, calcium hydroxide and sterile water, calcium hydroxide with sterile water and A. vera, calcium hydroxide and iodoform (metapex) and vaseline (control) against 18 strains of bacteria isolated from infected root canals of primary molar teeth using agar diffusion assay. It was concluded that A. vera + sterile water was found to have superior antimicrobial activity against most of the microorganisms, followed by ZOE + A. vera, calcium hydroxide + A. vera, ZOE, calcium hydroxide, Metapex in the descending order and Vaseline showed no inhibition.

Advantages

Aloe vera can be used as a local drug delivery system because of its various benefits[9]

Easily available

Easily applicable with minimal equipments

Cheap

No adverse effects.

Contra indications

Contraindicated in cases of known allergy to plants in the Liliaceae family, pregnancy and breastfeeding[17]

Oral aloe is not recommended during pregnancy due to theoretical stimulation of uterine contractions, and in breastfeeding mothers, it may sometime cause gastrointestinal distress in the nursing infant.

Side Effects

Topical

It may cause redness, burning and stinging sensation. Allergic reactions are mostly due to anthraquinones, such as aloin and barbaloin. It is best to apply in a small area first to test for possible allergic reaction.[17]

Systemic

Abdominal cramps, diarrhea, red urine, hepatitis, dependency or worsening of constipation. Prolonged use has been reported to increase the risk of colorectal cancer. Laxative effect may cause electrolyte imbalances (low potassium levels).

Conclusion

In contrast with traditional medicine modalities, A. vera is quite economical; it will markedly reduce both medical cost and invalidity. Dentistry is varying with induction of modern science to practice dentistry. The studies available in literature are short-term studies. Long-term studies are required with larger sample size. More research on its healing properties, antibacterial, antiinflammatory properties and releasing pattern as a local drug delivery system is required.