|Year : 2016 | Volume
| Issue : 2 | Page : 95-99
Role of herbs in endodontics
Rajendra Kumar Tewari, Bhumika Kapoor, Surendra Kumar Mishra, Ashok Kumar
Department of Conservative Dentistry and Endodontics, Dr. Ziauddin Ahmad Dental College, AMU, Aligarh, Uttar Pradesh, India
|Date of Web Publication||13-Oct-2016|
Department of Conservative Dentistry and Endodontics, Dr. Ziauddin Ahmad Dental College, AMU, Aligarh - 202 002, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Medicinal plants and herbs have attracted a lot of attention since the past few years. The market for drugs extracted from these plants and made from herbal extracts has seen a significant rise. India is known for its rich stock of medicinal plants. Among many, some herbs are rich in phytochemical content. These phytochemicals are useful in generating phytomedicines which have effects on the human body. In the field of endodontics, phytomedicines are a boon. They have been popularly used as analgesic, anti-inflammatory, sedatives, and antibiotics. They are most significantly used as endodontic irrigants. Phytotherapy has been a grand entrant in the drug market. The reason why herbal extracts have the potential to be highly popular is due to the side effects of synthetic medicines which alter microbiota.
Keywords: Endodontics, herbs, medicinal plants, phytotherapy
|How to cite this article:|
Tewari RK, Kapoor B, Mishra SK, Kumar A. Role of herbs in endodontics. J Oral Res Rev 2016;8:95-9
| Use of Herbs in Root Canal Treatment|| |
The anatomy of root canals is complex. The challenging part of a root canal treatment is to disinfect the root canal most effectively. Irrigation and intracanal medication primarily reduce the bacteria. Irrigants such as sodium hypochlorite (NaOCl), ethylenediaminetetraacetic acid (EDTA) solution, and chlorhexidine (CHX) have harmful side effects. Rarely, patients may be allergic to NaOCl and CHX. Intracanal medicaments such as calcium hydroxide cause collagen breakdown and hence weakening of radicular dentin. Triple antibiotic paste using minocycline, metronidazole, and ciprofloxacin have potential side effects of tooth discoloration. Such triple antibiotic paste also cause demineralization of dentin. Therefore, herbs that are more biofriendly and suited for dental irrigation prove to be better alternatives. ,, They are rich in antioxidant, antimicrobial, sedative, anxiolytic, and anti-inflammatory properties, thereby making them ideal for root canal disinfection.
| Various Kinds of Herbs Used in Endodontics|| |
Plants, animals, and minerals are all sources of phytotherapeutic substances. Various such herbs are as follows:
This is used as a chelating agent due to the presence of citric acid in its fruits. The presence of tannins, quinones, flavonoids, gallic acid, and Vitamin C makes it an ideal agent to remove the smear layer. It is a good replacement to NaOCl for root canal irrigation.  Its free radical scavenging and antimicrobial property is an efficient tool to prevent the formation of biofilm. Triphala (IMPCOPS Ltd., Chennai, India) is an Indian Ayurvedic herbal formulation consisting of dried and powdered fruits of three medicinal plants, Terminalia bellirica (Bibhitaki), Terminalia chebula (Halituki), and Emblica ofﬁcinalis (Amalaki) (green tea polyphenols [GTPs]; Essence and Flavours, Mysore, India).
According to Prabhakar et al., 5% of NaOCl exhibited excellent antibacterial activity in both 3-week and 6-week biofilm, whereas triphala and mixture of a tetracycline isonomer, citric acid, and a detergent showed complete eradication only in 3-week biofilm. 
It is popularly known as Indian mulberry. Owing to its antibacterial and antimicrobial properties, it is popularly used as a root canal irrigant. Its prime components are L-asperuloside and alizarin.  Other phytochemicals present in it are lignans, oligopolysaccharides, flavonoids and catechins. Besides, it also displays antitumor, anthelmintic, analgesic, hypotensive, anti-inflammatory, and immune-enhancing properties. It is an effective chelating agent and can inhibit carcinogen-DNA adduct formation. ,
Murray et al. evaluated Morinda citrifolia juice (MJC) in conjunction with EDTA as a possible alternative to NaOCl. The efficacy of MJC was similar to NaOCl in conjunction with EDTA as an intracanal irrigant. MJC appears to be the first fruit juice to be identified as a possible alternative to the use of NaOCl as an intracanal irrigant. 
Poplars, conifers, and Generic clusia flowers are its prime sources; popularly used as root canal irrigant, intracanal medicament, and storage medium treatment of periodontal ligament. ,,,
Oncag et al. evaluated the efficacy of propolis as an intracanal medicament against Enterococcus faecalis. The study revealed that propolis had good in vitro antibacterial activity against E. faecalis in the root canals, suggesting that it could be used as an alternative intracanal medicament. 
It is commercially available by Bioessens Limitada (Rua Tomas Sepe, 320-Jardim da Gloria-Cotia-SP, Brasil).
The Indian neem/margosa tree is rich in its antioxidant properties and is an effective alternate to NaOCl in root canal irrigation. Candida albicans is the most common fungus seen in the root canals. According to a study conducted, NaOCl and propolis groups exhibited highest antimicrobial efficacy against C. albicans. It was followed by the Azadirachta indica (neem) group. ,
When used in combination with Aloe vera, it has been tested to be effective in decontaminating Gutta-percha (GP) cones. Thus, it is an effective disinfectant before a root canal surgery. Its ethanol extracts are efficient in treating E. faecalis and C. albicans.
Orange oil comprises limonene, aliphatic hydrocarbon alcohols, and aldehydes such as octanal.  It serves as a good replacement for chloroform and xylene for GP softening and removing endodontic sealers in retreatment. Orange oil does not have any harmful effect, has low solubility in water, and is soluble in alcohol. It is used in pharmaceuticals for fragrance and flavor and also has an expectorant action.
A recent study concluded that xylene was the most effective in dissolving root canal sealers than other organic solvents. Essential oils (eucalyptus oil and orange oil) were found similar in their ability to dissolve Apexit Plus and Endomethasone N. 
Mushtaq et al. concluded that xylene, refined orange oil, and tetrachloroethylene can be used for softening GP/resilon during retreatment with various techniques. Xylene proved to be best solvent both for GP and resilon. 
Orange oil is an excellent alternative solvent as compared to potentially toxic solvents, being used either on zinc oxide-eugenol cement or to soften and dissolve GP. 
An in vitro mammalian test system was done to find genotoxic or cytotoxic effects of chloroform and eucalyptol by single cell gel (comet) assay and trypan blue exclusion test, respectively. Chloroform and eucalyptol were exposed to Chinese hamster ovary cells in culture directly for 3 h at 37°C at final concentrations ranging from 1.25 to 10 μl/mL. The negative control group was treated with vehicle control (phosphate-buffered solution), and the positive control group was treated with methyl metasulfonate (MMS, at 1 μg/mL concentration). The results showed that both GP solvents were cytotoxic at concentrations of 2.5, 5, and 10 μl/mL (P < 0.05). On the other hand, both solvents did not induce DNA breakage at 1.25 μl/mL concentration. It was concluded that both chloroform or eucalyptol are strong cytotoxicants; however, they may not be a factor that increases the level of DNA lesions in mammalian cells. 
It is commercially available as refined orange oil (Nipponshika, Yakuhin Co. Ltd, Shimonoseki, Japan).
It is rich in antimicrobial property that is emitted by bacteria cell membrane and its disruption. The prime use of carvacrol is inhibiting Escherichia More Details coli and Pseudomonas aeruginosa, repair of periapical tissue, and stimulating pulpal fibers, thus making it ideal for endodontic usage. 
It is commercially available by various companies such as Sigma-Aldrich, Biocore, MP Biomedicals, Life Chemicals, and Glentham Life Sciences Ltd.
Green tea in low concentration has been tested to be able to create an inhibition zone around E. faecalis slightly lesser than NaOCl 1%. The antimicrobial effect increases in higher concentrations of extracts of green tea.  Green tea is made from Camellia sinensis. Its origin lies in Japan and China, though it is widely available worldwide now for its health benefits, especially antioxidant properties. The GTP are rich in antioxidants, are anticariogenic, and act as an anti-inflammatory agent. They are thermogenic, probiotic, and also possess antimicrobial properties that inhibit formation of biofilm. The presence of natural fluorides makes it an efficient antiplaque and chelating agent. 
Salvadora persica solution (Miswak-Siwak)
This has its root in ancient Indian Ayurveda. They are obtained from trees with bitter roots and are rich in trimethyl amine, salvadorime chloride, and fluoride. It is enriched with alcoholic extracts which have active antimicrobial properties which prevent the formation of biofilm. It is also an effective substitute for NaOCl in root canal irrigation. Fifteen percent alcoholic extracts of it have maximum antimicrobial action. It can be used as a substitute for NaOCl and chlorhexidine as root canal irrigant. 
A recent study was conducted to assess the efficacy of chlorhexidine and herbal mouthwash in reducing the toxicity or microbial load on the aerosol produced during ultrasonic scaling. A commercially available herbal mouthrinse prepared from pilu 5 mg (Salvadora persica), bibhitaka 10 mg (T. bellirica), nagavalli 10 mg (Piper betle), peppermint satva 1.6 mg (Mentha spp), and yavanisatva (thymol) (Carum copticum) 0.4 mg was used. Both the test groups were compared as to which rinse would be more effective in reducing the colony-forming units on the blood agar plates in comparison to control group. There was a statistically significant reduction in Colony-Forming Unit count in both experimental groups, CHX (B) - 56.75 and herbal (C) - 47.38 as compared to control group (A) - 114.50. However, the difference between the CHX (B) and herbal (C) groups was not statistically significant showing that the herbal mouth rinse was as effective as CHX for preprocedural rinsing. 
It is an effective chelating agent that helps in cleaning the smear layer better than NaOCl before root canal irrigation. What aids in this are ingredients such as chamazolene, capric acid, and caprylic acid, chlorogenic acid. Since ancient times, it has been used as an anti-inflammatory, analgesic, antimicrobial, antispasmodic, and sedative. This makes it ideal for endodontic use. A study concluded that the efficacy of chamomile to remove smear layer was superior to NaOCl alone but less than NaOCl combined with EDTA. It is effective in inhibiting infections of gingivae and oral cavity, making it an ideal component for various mouthwashes. It treats mucositis and lesions. 
It is worldwide commercially available in pure, undiluted form by various companies such as Eden Garden Aromatherapy.
Tea tree oil
The evergreen tree is native to Australia in wet lowland locations and grows about 10-25 feet. It has papery white bark, dark green needle-like leaves, and colorful flowers. It is commercially available by Eden Garden Aromatherapy. It is a great antibacterial and antifungal agent due to the presence of terpinen-4-ol. It can be used as an effective root canal irrigant. However, it is not an ideal substitute for EDTA or NaOCl. Throat irritation, stings, burns, wounds, and skin infections can be treated with it. It is also effective in periodontal tissue healing as well as a mild solvent. 
Although not in a full-fledged fashion, it is used for intracanal dressing due to the presence of ethyl acetate. It has antifungal, antioxidant, and anxiolytic properties. Other beneficiary properties include platelet anti-aggregating effect, and human immunodeficiency virus-inhibitory treatment. In endodontics, it is primarily used to treat root canal infections due to it antimicrobial property that prevents the formation of biofilms and is effective against harmful pathogens. 
A study evaluated in vitro, the antimicrobial activity of rough extracts from leaves of Arctium lappa and their phases. The microorganisms, commonly found in the oral cavity, specifically in endodontic infections, were used: E. faecalis, Staphylococcus aureus, P. aeruginosa, Bacillus subtilis, and C. albicans. It was concluded that the A. lappa constituents exhibited a great microbial inhibition potential against the tested endodontic pathogens. 
Lime is rich in citric acid which is effective in clearing the smear layer, thereby acting as a chelating agent. It has antibacterial properties making it an ideal root canal medicament without any side effect. 
In a study by Abuzied and Eissa, fresh lemon solution was shown to have wide antibacterial efficiency including E. faecalis and hence can be used as an intracanal medicament. 
Garlic (Allium sativum)
The allicin present in garlic makes it a popular antibacterial and antimicrobial agent. It is an effective alternative to NaOCl as the allicin present destroys cell wall and cell membrane of root canal bacteria. 
The rhus plant is enriched with tannins and acid which reflect antibacterial, antifungal, antimicrobial, antioxidant, and anti-inflammatory properties. They aid in unblocking the dentinal tubules. 
The 30% Jieeryin solution is an ideal alternative to NaOCl, popular for its detoxifying, heat cleaning, and anti-inflammatory properties, it is a popular product in root canal irrigation. 
Aloe vera gel
A. vera is rich in aloins and aloe-emodin. The presence of anthrax quinine makes it effective agent against the formation of Streptococcus pyogenes and E. faecalis.  It is an effective antibacterial due to protein synthesis in bacterial cells and is rich in vitamins, minerals, enzymes, sugars, lignin, saponins, salicylic acids, and amino acids. The aloin and aloe-emodin are the active constituents of the gel.
It is popularly used for its soothing, moisturizing, and healing properties. Thus, they are ideally used on trauma, burns, or scratch spots. It has antifungal properties. In endodontics, it is also popular for its anti-inflammatory effects. It is used to treat P. aeruginosa, infections, inflammation, lesions, aphthous ulcers, and canker sores. 
A. vera extract can also be used as canal lubricant. During closed dressings, the cotton pellet with camphorated mono-parachlorophenol drops could be added with a drop of A. vera gel and then sealed with temporary restorations. 
In an in vitro study, Bhardwaj et al. compared the antimicrobial activity of natural extracts of M. citrifolia, papain, and A. vera (all in gel formulation), 2% CHX gel, and calcium hydroxide, against E. faecalis. The antibacterial activity was measured at two depths (200 and 400 μm) and at three time intervals (1, 3, and 5 days). The inhibition of growth in all the groups was statistically significant in comparison to the control group (saline). Two percent CHX gel was the most effective against E. faecalis to the depth of 400 μm on all days of incubation. Calcium hydroxide showed the least effectiveness. Among the natural intracanal medicaments, M. citrifolia gel consistently exhibited good inhibition up to the day 5 followed by A. vera gel and papain gel. 
A study was conducted to evaluate the antimicrobial efficacy of A. vera and its effectiveness in decontaminating GP cones. A concentrated extract of A. vera was used to check for the antimicrobial efficacy using the agar well diffusion method. The presence of zones of diffusion was identified against three common GP contaminants, namely, E. coli, E. faecalis, and S. aureus. New GP cones were decontaminated for 1 min using A. vera gel and then placed in thioglycolate broth to check for the presence of turbidity. The zones of inhibition on the agar plate were measured as 24 mm, 21 mm, and 24 mm, respectively. The broth remained clear even after 48 h of incubation. It was concluded that A. vera is effective as a GP decontaminant and can be used as a medium for storage of GP cones. 
It has properties to injure the cell membrane and inhibit DNA polymerase. Thus, is used as an effective treatment for E. faecalis. 
Bakuchiol was isolated from the seeds of Psoralea corylifolia. Bakuchiol showed bactericidal effects against all bacteria tested, including Streptococcus mutans, Streptococcus sanguis, Streptococcus salivarius, Streptococcus sobrinus, E. faecalis, Enterococcus faecium, Lactobacillus acidophilus, Lactobacillus casei, Lactobacillus plantarum, Actinomyces viscosus, and Porphyromonas gingivalis, with minimum inhibitory concentrations ranging from 1 to 4 μg/mL and the sterilizing concentration for 15 min ranging from 5 to 20 μg/mL. 
It is popularly known as the guava. Its leaves are rich in guaijaverin that inhibits S. mutans and S. aureus formation that lead to plaque. This plant is enriched with vitamins, phenolic compounds, sesquiterpene alcohols, cineol, tannins, tripentnes, and flavonoids. The Psidium guajava is also rich in carotenoids such as beta-carotene, lycopene, and beta-cryptoxanthin, Vitamin C, and polyphenols. Such rich ingredients make it effective for treatment of E. faecalis. It has anti-inflammatory, antimicrobial, antioxidant, and antimutagenic properties. 
It is rich in anthocyanins, glucose, ascorbic acid, glucose, ellagic acid, amino acids, quercetin, flavonoids, epigallocatechin, quercetin, gallic acid, amino acids, and caffeic acids. This makes it an effective antioxidant, antibacterial, antimicrobial. It is effective to treat gingivitis, ulcers, aphthous stomatitis, and against periodontal pathogens. 
It is rich in tannins and phenolic compound, it is ideally used to treat E. faecalis. It thus has antimicrobial properties. 
Syzygium aromaticum/clove tree
Clove is known to have antioxidant, antibacterial, and antimicrobial properties. Clove oil has sedative action on the pulpal inflammation. 
Its usage is popular since ancient times due to antibacterial, antimicrobial, anti-inflammatory, and antiseptic properties. It is applied on spots where wounds, abrasions, toothache, or swelling is experienced. 
In ancient times, cranberry was used to treat stomach aches, scurvy, and other liver diseases. They are rich in polyphenols and flavonoids. Dental caries can be treated with them. They have antibacterial and antimicrobial properties, thereby preventing inhibition of many pathogens and biofilms. 
It is rich in phospholipase A2 inhibitors making it an ideal anti-inflammation drug to be used for the intracanal medicament. 
| Conclusion|| |
One major benefit of herbs is in the root canal disinfection. Intracanal medicaments are popularly used for disinfecting the canal. Nevertheless, they have various disadvantages. There have been instances where bacterial remnants increase the possibility of reinfections. Thereby, the potential side effects and keeping in mind the safety aspect using herbs and plants as substitutes may seem to be a more viable option.
Herbal substitutes have negligible to almost no side effects. It has been reflected since ancient times, the Ayurveda has been widely popular for the usage of these herbs. These medicinal plants have anti-inflammatory, antibacterial, and antioxidant properties that inhibit pathogens greatly without effecting the dental tissues. They not only heal but also protect by increasing immunity.
More tests and research need to be done to discover better treatments and usage of these herbs and to analyze their side effects if any. At present, the usage of natural extracts in dental products has gained popularity due to an inclination toward natural treatments.
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Conflicts of interest
There are no conflicts of interest.
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