REVIEW

Herbal Usage In Endodontics- A Review

Madhu Pujar, 1 Saleem Makandar 2
surfaces.[4] Commonly they are the only strains recovered from the obturated root canal. Hence, achieving predictable long term success of the root canal treatment requires effective debridement and The major objective in root canal treatment is to disinfect the entire disinfection of entire root canal system and prevention root canal system. Although cleaning and shaping and use of of reinfection.[5-6] antimicrobial medicaments are effective in reducing the bacterial Although chemo-mechanical preparation of root load some bacteria do remain behind and multiply, causing canal is able to reduce the number of bacteria, the reinfection of the canal. Considering the ineffectiveness , potential intracanal medicament with anti- bacterial action is side effects and safety concerns of synthetic drugs, the herbal required to maximize the disinfection of root canal alternatives for endodontic usage might prove to be advantageous. system in infected cases.[7] Several chemicals and therapeutic agents are used to disinfect the root canal. Key words: Propolis, MCJ, Arctium lappa, Triphala and GTP, German The most effective among them are Sodium chamomile and tea tree oil Hypochlorite (NaOCl), 2% solution of CHX and Ca(OH)2, which possess varying degree of antibacterial activity.[8] Sodium Hypochlorite has been the most widely used root canal irrigating solution for several decades due to its excellent properties of tissue dissolution and antimicrobial activity. But it has several undesirable characteristics such as tissue toxicity, risk of Introduction emphysema when overfilling, allergic potential, disagreeable smell and taste and inability to remove the When the Dental pulp undergoes pathological smear layer.[2,4,9] The smear layer has been postulated changes due to trauma or caries, microorganisms enter to be an avenue for leakage as well as to provide a the pulp chamber and invade the anatomic substrate for bacterial growth and ingress.[1] CHX also irregularities of the root canal system.[1] Although a has been used effectively to irrigate the canals and as substantial number of bacterial species have been an intracanal medicament due to its broad spectrum identified as inhabitants of the oral cavity, because of antimicrobial activity, biocompatibility and ability to bacterial interactions, nutrient availability and low O2 disinfect the dentinal tubules against Enterococcus potentials in root canals, the number of bacterial faecalis.[10] However, the use of CHX as an irrigant is species present in endodontic infections is restricted. generally restricted because it can discolor the teeth These selective conditions lead to the predominance of and tongue, can cause loss of taste, burning sensation facultative and anaerobic microorganisms, particularly of the oral mucosa and subjective dryness of oral cavity. Enterococcus faecalis which is a dominant enterococcus The effectness of CHX to clean the root canal walls is species. It survives in the root canal as a single organism generally found to be inferior to NaOCl.[2] Ca(OH)2 has without the support of other bacteria and multiply, been advocated as an intracanal medicament because causing infection that stimulates local bone of its antibacterial, antiresorptive and tissue dissolving resorption.[2] The cells of E-faecalis remain viable and properties. However, Ca(OH)2 is not effective in are more resistant to endodontic treatment. They also eliminating bacteria from the dentinal tubules. It was have the capability to invade the dentinal tubules and reported that Enterococcus faecalis present in the adhere to the collagen in presence of human serum, dentinal tubules was resistant to Ca(OH)2 over 10 thus acting as a pathogen in failed endodontically days.[10] treated teeth.[3] The mode of growth of E-faecalis is Owing to the potential side effects, through the biofilm formation that allows safety concerns and ineffectiveness of conventional microorganisms to stick to and to multiply on the allopathic formulations, consumption of preparations surfaces.[4] Commonly they are the only strains IJCD JANUARY, 2011 2(1) 34 from Dentistry recovered from the obturated root canal. Hence, of Contemporary medicinal plants has increased over the last few 2011 Int. Journal decades.[1-2] Herbal or natural products have been achieving predictable long term success of the root

ABSTRACT

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allopathic formulations, consumption of preparations from medicinal plants has increased over the last few decades.[1-2] Herbal or natural products have been used in dental and medical practice for thousands of years and have become even more popular today due to their high antimicrobial activity, biocompatibility, anti-inflammatory and anti-oxidant properties.[10] According to WHO herbal medicine is defined as plant derived material or preparation which contains raw or processed ingredients from one or more plants with therapeutic values.[11] Botanically speaking a herb is any plant that lacks the woody tissue characteristics of shrubs or trees. They are plants used medicinally for their flavor or scent. With herbal, homeopathic remedies and holistic or alternative medicine gaining increasing popularity among the public, as dental practioners we face a responsibility to explore and understand these products and extrapolate their implications on our current patient management strategies.[12] The different herbs and their clinical implications in Endodontics Propolis The chemical composition of Propolis is complex. The most important pharmacologically active constituents in propolis are flavonoids, phenolics and aromatics. It is believed that flavonoids account for much of the biologic activity in propolis.[10] Propolis exhibits a wide range of biologic activities, including antimicrobial, anti-inflammatory, antioxidant, anesthetic and cytotoxic properties.[13] The antiinflammatory property of propolis is due to the presence of caffeic acid and phenethyl ester (CAPE) in propolis. Ethanol extract of propolis presents good properties for endodontic use, such as promoting bone regeneration and inducing hard tissue bridge formation in pulpotomies or pulp capping. Propolis is dispensed in various forms. Propolis being a good antimicrobial and anti-inflammatory agent, can serve as a better intracanal irrigant and intracanal medicament.[14-15] A comparative evaluation on microbial efficacy of propolis, NaOCl and saline when used as intracanal irrigants indicated that the propolis has antimicrobial activity equal to that of NaOCl. The antibacterial efficacy of three commonly used intracanal medicaments with propolis against Enterococcus faecalis has been compared. They concluded that propolis had good invitro antibacterial activity against Enterococcus faecalis in the root canals, suggesting that it could be used as an alternative intracanal medicament.[16] The antimicrobial activity of propolis with Ca(OH)2 as intracanal, medicament against Enterococcus faecalis found that propolis was effective in eliminating the microorganisms.[5] is indigenous to tropical countries and is considered as an important folkmedicine. It is also called as Indian Mulberry, Ba ti tian, Nono or Nonu, Cheese fruit and Nhan in various cultures throughout the world. Its juice has a broad range of therapeutic effects including antibacterial, anti-inflammatory, antiviral, antitumor, antihelmenthic, analgesic, hypotensive, antiinflammatory and immune enhancing effects. The use of Morinda Citrifolia juice as an endodontic irrigant might be of interest to patients and endodontic professionals as part of the growing trend to seek natural remedies as part of dental treatment and might be advantageous because it is a biocompatible antioxidant and not likely to cause the severe injuries to patients that might occur through NaOCl accidents. An invitro study compared the effectiveness of MCJ with NaOCl and CHX to remove the smear layer from the root canal walls of instrumented teeth. It was concluded that the efficacy of Morinda Citrifolia was similar to NaOCl in conjunction with EDTA as an intracanal irrigant. The antimicrobial activity of 2% CHX gel propolis, Morinda Citrifolia juice and Ca(OH)2 has been compared on E.faecalis infected root canal dentin at two different depths and three intervals. It was concluded that Propolis and Morinda Citrifolia were effective against E. faecalis in dentin on extracted teeth.[14] Morinda Citrifolia appears to be the first juice to be identified as a possible alternative to the use of NaOCl as an intracanal irrigant. Arctium Lappa Arctium lappa is a plant brought from Japan and acclimated in Brazil, which is widely used in popular medicine all over the world for its well-known therapeutic applications. It has anti-bacterial and antifungal activity, diuretic, anti-oxidant and anxiolytic action, platelet anti-aggregating effect and HIVinhibitory action. In Dentistry, Arctium lappa has been investigated due to its antimicrobial potential against oral microorganisms, specifically those associated with endodontic infections. An in vitro evaluation of antimicrobial activity of Arctium lappa against microorganisms specifically found in endodontic infections showed a great microbial inhibition of Arctium lappa against the tested endodontic pathogens. The microbial inhibition potential of Arctium lappa observed in this study opens perspective for its use as an intracanal medication.[16]

Triphala and Green tea polyphenols(GTP) Triphala is one of the well known Indian Ayurvedic herbal formulation consisting of dried and powdered fruits of three medicinal plants namely Terminalia Bellerica, Terminalia Chebula and Emblica Officinalis.[4] The formulation is prescribed in the first line treatment of ailments and is used as laxative, detoxifying agent and rejuvenator. The polyphenols found in Green tea are more commonly known as Morinda Citrifolia (NONI) flavanols or catechins. Green tea polyphenols have Morinda Citrifolia commercially known as Noni, is significant antioxidant, anticariogenic, antiindigenous to tropical countries and is considered as an IJCD JANUARY, 2011 2(1) inflammatory, thermogenic, probiotic and antimicrobial 35 important folk 2011 Int. Journal of Contemporary Dentistry properties in numerous human, animal and in vitro

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significant antioxidant, anticariogenic, antiinflammatory, thermogenic, probiotic and antimicrobial properties in numerous human, animal and in vitro studies.[17] It can be used as an effective antiplaque angent because of its antioxidant properties and it can effectively inhibit the biofilm formation.[18] Green tea polyphenols (GTPs: Essence and flavours Mysore, India). It is a traditional drink of Japan and China and is prepared from the young shoots of tea plant Camellia Sinensis.[4] The leaves from the tea plant contain polyphenolic components with activity against a wide spectrum of microbes.[19] The anti-oxidative properties of unfermented tea can be attributed to the ability of the polyphenols contained in the leaves of Thea chinensis, especially the gallocatechins, to inactive free radicals. GTPs have demonstrated antioxidant, anti-inflammatory and antimicrobial properties in numerous human, animal, in vitro studies.[20] Green and black teas both contain flavonoids that inhibit the growth and activity of the bacteria associated with tooth decay. Tea also contains natural fluoride, which may be helpful in preventing dental caries. Triphala and GTPs are proven to be safe, containing active constituents that have beneficial physiologic effect apart from its curative property such as anti-oxidant, anti-inflammatory and radical scavenging activity and may have an added advantage over the traditional root canal irrigants. An in vitro study conducted to evaluate the antimicrobial efficacy of Triphala, GTPs, MTAD, and 5% Sodium Hypochlorite against E-faecalis biofilm formed on tooth substrate showed maximum antibacterial activity with NaOCl and statistically significant antibacterial activity with Triphala, GTPs and MTAD.[4] antibacterial and antifungal properties.[11] In order to avoid the undesirable effects of NaOCl, an SEM study was conducted using two medicinal plants i.e german chamomile extract and tea tree oil which might disinfect the root canal system with less toxicity when used as irrigants. It was concluded that the efficacy of chamomile to remove smear layer was superior to NaOCl alone but less than NaOCl combined with EDTA.[1]

Conclusion
The major advantages of using herbal alternatives are easy availability, cost effectiveness, increased shelf life, low toxicity and lack of microbial resistance reported so far. The in vitro observations of herbal products appear promising but preclinical and clinical trials are needed to evaluate the biocompatibility and safety factor before they can conclusively be recommended as intracanal irrigating solutions and medicaments. Herbs are generally safe if used with proper knowledge, but they can be harmful if misused. Many herbal drugs bare potential risk, side effects and drug interactions that may affect our safe practice of dentistry. Hence herbs should only be used for treatment procedures that have been established to be effective and with minimal risk involved.

References
1) M.S. Sadr Lahijani, H.R. Raoof Kateb, R. Heady et.al .The effect of German chamomile (Marticaria recutitia L.) extract and tea tree( Melaleuca alternifolia L.) oil used as irrigants on removal of smear layer: a scanning electron microscopy study. Int Endod J 2006;39:190-95.

German chamomile and tea tree oil The German chamomile (Marticaria recutitia L.) has been used for centuries as a medicinal plant 2) Peter E. Murray, Romi M. Farber, Kenneth N. mostly for its anti-inflammatory, analgesic, antiNamerow et.al. Evaluation of Morinda citrifolia as an microbial, antispasmic and sedative properties. Endodontic Irrigant. J Endod 2008; 34: 66-70. German chamomile, in particular, is the most commonly used variety. It is an annual plant, native to 3) R.M.Love. Enterococcus faecalis- a mechanism for its Europe and Western Asia, and is used in parts of the role in endodontic failure- Int Endod J 2001;34:399-405. world as a table tea. It is infact the flower of the chamomile plant, which contains a wide variety of 4) J.Prabhakar, M.Senthikumar, M.S.Priya et.al. active chemical components, which are thought to be Evaluation of Antimicrobial Efficacy of Herbal responsible for many of its medicinal applications. Alternatives (Triphala and Green Tea Polyphenols), Chamomile was also found to be effective when used MTAD, and 5% Sodium Hypochlorite against as a mouthwash to treat irritations and minor Enterococcus faecalis Biofilm Formed on Tooth infections of the mouth and gingivae and is also used Substrate: An In Vitro Study. J Endod 2010;36:83-86. in some toothpaste. Tea tree oil (Melaleuca alternifolia) as it is 5) D.Kandaswamy, N.Venkateshbabu, D.Gogulnath more commonly known, is a native Australian plant et.al.Dentinal tubule disinfection with 2% chlorhexidine with many properties such as being an antiseptic, an gel, propolis, morinda citrifolia juice, 2% povidone antifungal agent and a mild solvent. Tea tree oils iodine, and calcium hydroxide. Int endod J 2010;43:419major active component is terpinen-4-ol(typically 3023. 40%). This compound is responsible for its antibacterial and antifungal properties.[11] 6) Thomas R. Dunavant, John D. Regan, Gerald N. IJCD of In order to avoid the undesirable effects JANUARY, 2011 2(1) 36 Glickman et.al. Comparative Evaluation of Endodontic 2011 NaOCl, an SEM study was conducted using Int. Journal of Contemporary Dentistry Enterococcus-faecalis Biofilms. J Endod two Irrigants against

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6) Thomas R. Dunavant, John D. Regan, Gerald N. Glickman et.al. Comparative Evaluation of Endodontic Irrigants against Enterococcus-faecalis Biofilms. J Endod 2006;32:527-31. 7) B.P.F.A. Gomes, S.F.C.Souza, C.C.R. Ferraz et.al. Effectiveness of 2% chlorhexidine gel and calcium hydroxide against Enterococcus faecalis in bovine root dentine in vitro. Int Endod J 2003;36:267-75. 8) Fabiane Bortoluci da Silva, Juliano Milanezi de Almeida, Simone Maria Galvao de Sousa. Natural medicaments in endodontics a comparative study of the anti-inflammatory action- Braz Oral Res 2004;18: 174-9 9) Zahed Mohammadi, Yasd, Iran. Sodium Hypochlorite in Endodontics: an update review. IDJ 2008;58:329-41. 10) Dilsah Cogulu, Atac Uzel, Kadriye Sorkun et.al. Efficacy of propolis as an intracanal medicament against Enterococcus faecalis- Gen Dent 2006;54:31922 11) Milind Parle, Nitin Bansal. Herbal medicines: Are they safe? Natural Product Radiance 2006;5: 6-14. 12) Katty Karimi. The impact of current alternative herbal remedies on dental patient management- Gen Dent 1999;47:264-6 13) Hyun Koo, Pedro L. Rosalen, Jaime A. Cury et.al. Effects of Compounds Found in Propolis on Strptococcus mutans Growth and on Glucosyltransferase Activity. ANTIMICROBIAL AGENTS AND CHEMOTHERAPY 2002;46:1302-09. 14) Flaviana Bombarda de Andrade Ferreira, Sergio Aparecido Torres, Odila Pereira da Silva Rosa et.al. Antimicrobial effect of propolis and other substances against selected endodontic pathogens. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007; 104:709-16 15) Abhishek Parolia, manuel S. Thomas, M. Kundabala et.al. Propolis and its potential uses in oral health. Int.J Med. Med .Sci 2010; 2:210-15. 16) Julaina Vianna, Debora Cristina Baldoqui, Jose Odair et.al. Antimicrobial Activity of Arctium lappa Constituents Against Microorganisms Commonly Found in Endodontic Infections- Braz Dent J 2005;16:192-96. 17) Pulok K. Mukherjee, Sujay Rai, Sauvik Bhattacharyya et.al. Clinical study of Triphala- A Well Known Phytomedicine from India. IJPT 2006;5:51-4. 18) L. Jagadish, V.K. Anand kumar, V. Kaviyarasan. Effect of Triphala on dental bio-film. Indian J.Sci.Technol. 2009;2:30-3. 19) Peter W. Taylor, Jeremy M.T. Hamilton- Miller, Paul D. Stapleton. Antimicrobial properties of green tea catechins. Food Sci Technol Bull 2005;2:71-81. 20) Stephen foster. Green Tea.[Monograph online]. Medicine review monograph;2002, available at. http//www.thorne.com/media/alternative_m. 21) The Antimicrobial Activity of Salvadora Persica Solution( MISWAK- SIWAK) as Root Canal Irrigant(A Comparative Study)- University of Sharjah Journal of Pure & Applied Sciences 2007;4: 69-91 22) Anticaries Effects of Polyphenolic Compounds from Japanese Green Tea Caries Res 1991;25:438-43 23) Antibacterial Effects of Various endodontic Medicaments on selected Anaerobic Bacteria- J Endod;19:1993 24) Antibacterial Potentials of Some Herbal Preparations Available in India- Research Journal of medicine and Medicine Sciences 2009;4:224-7 25) The smear layer in endodontics- a reviewInternational Endodontic Journal 2010;43:2-15 26) Antibacterial Activity of Propolis Ethanol Extract Against Streptococcus mutans as Influenced by Concentration Temperature, pH and Cell age- Journal of Food and Drug Analysis 2007;15:75-81

About the Authors

Professor Maratha Mandals Nathajirao G Institute of Dental Sciences, Karnataka, India.

1) Dr Madhu Pujar

Halgekar Belgaum.

Senior Lecturer Maratha Mandals Nathajirao G Institute of Dental Sciences, Karnataka, India.

2) Dr Saleem Makandar

Halgekar Belgaum.

e mail: saleemdm@gmail.com
Address for correspondence

Dr Madhu Pujar

Professor Department of Conservative Dentistry and Endodontics Maratha Mandals Nathaji Raoji Halgekar Institute of Dental Sciences, Belgaum. Karnataka, India.

e mail: madhupujar.r@gmail.com

37 Miller, 19) Peter W. Taylor, Jeremy M.T. Hamilton- 2011 Int. Journal of Contemporary Dentistry Paul D. Stapleton. Antimicrobial properties of green

IJCD JANUARY, 2011 2(1)