|Year : 2019 | Volume
| Issue : 2 | Page : 72-76
Aloe vera on wound healing after periodontal flap surgery in chronic periodontitis patient: A randomized control trial
Anuja D Hudwekar, Amol Beldar, Supriya Murkute, Shruti Shankarrao Lendhey, Mitali Thamke
Department of Periodontology and Implantology, MGV's KBH Dental College and Hospital, Nashik, Maharashtra, India
|Date of Submission||14-Apr-2019|
|Date of Acceptance||19-Jun-2019|
|Date of Web Publication||15-Jul-2019|
Anuja D Hudwekar
Department of Periodontology and Implantology, MGV's KBH Dental College and Hospital, Nashik, Maharashtra
Source of Support: None, Conflict of Interest: None
Introduction: Aloe vera is known for its wound healing and anti-inflammatory properties which may be used for periodontal healing. Early healing of the gingival and periodontal wounds promotes favorable treatment outcome.
Aim: This study aimed to evaluate the efficacy of Aloe vera on wound healing after periodontal flap surgery.
Materials and Methods: Ten patients with chronic periodontitis indicated for periodontal flap surgery were included in this single-blinded, split-mouth, randomized controlled clinical trial. The selected sites were allocated into test and control sites by using simple randomization. After flap surgery, only the test sites received an application of A loe vera extract (gel). Postoperative healing was assessed using the Early Healing Index (EHI) after the 1st week and the Healing Index (HI) after the 1st, 2nd, 3rd, and 4th weeks.
Results: Better initial healing was observed in the test sites in comparison to the control sites in the 1st postoperative week as recorded by the EHI and HI, whereas no significant differences were observed at the 2nd, 3rd, and 4th weeks.
Conclusion: Application of Aloe vera extract was effective in significantly improving healing scores in the 1st postoperative week.
Keywords: Aloe vera, chronic periodontitis, Healing index, wound healing
|How to cite this article:|
Hudwekar AD, Beldar A, Murkute S, Lendhey SS, Thamke M. Aloe vera on wound healing after periodontal flap surgery in chronic periodontitis patient: A randomized control trial. J Oral Res Rev 2019;11:72-6
|How to cite this URL:|
Hudwekar AD, Beldar A, Murkute S, Lendhey SS, Thamke M. Aloe vera on wound healing after periodontal flap surgery in chronic periodontitis patient: A randomized control trial. J Oral Res Rev [serial online] 2019 [cited 2019 Dec 12];11:72-6. Available from: http://www.jorr.org/text.asp?2019/11/2/72/262894
| Introduction|| |
Chronic periodontitis has been defined as an infectious disease resulting in inflammation within the supporting tissues of the teeth, progressive attachment loss, and bone loss. Several techniques have been employed for the treatment of periodontal pockets. The most common technique is flap surgery for periodontal reattachment, which demands close postoperative adaptation for the mature, gingival connective tissue onto the prepared tooth surface. The complications for this procedure include postoperative pain, swelling, and bleeding.
Healing of wound is a classical example of regeneration and repair. Irrespective of the intention and the modalities of surgery, periodontal wound healing always begins with a blood clot in the space maintained by the closed flap after suturing. Reduced patient discomfort and enhanced compliance helps in faster rehabilitation of patients. There are several factors that retard the process of healing, promote continuance of inflammation, and induce necrotic or hyperplastic responses.
Aloe vera is a cactus-like plant, which is a member of the Lilaceae family. A loe vera plant has a long history of healing power. It has the ability to heal burns and cuts and soothe pains in dermatological field. Reported pharmacological actions of Aloe vera include anti-inflammatory, antibacterial, antioxidant, antiviral, and antifungal actions as well as hypoglycemic effects. The dental effects of Aloe vera are multiple. It is extremely useful in the treatment of gum diseases such as gingivitis and periodontitis. It reduces bleeding, inflammation, and swelling of the gums. It acts as a powerful antiseptic in pockets where normal cleaning is difficult, and its antifungal properties help gently in treating the problem of denture stomatitis, apthous ulcer, and cracked and split corners of the oral cavity. It is a powerful healing promoter which can be used following tooth extraction.,,
Although the medicinal use of Aloe vera has been reported, less literature is available regarding its use in the field of dentistry. Therefore, the aim of this study was to evaluate the efficacy of Aloe vera on wound healing following periodontal flap surgery in chronic periodontitis patients.
| Materials and Methods|| |
This study was a split-mouth, randomized controlled trial, carried out at the Department of Periodontics, M.G. Vs KBH Dental College, Nashik, Maharashtra, India. Ten patients requiring periodontal flap surgery on at least two interproximal sites on either side of the maxillary or mandibular arch were included in the study.
- Patients aged between 25 and 55 years with moderate-to-severe chronic periodontitis
- Periodontal pockets >5 mm
- Systemically healthy patients fit for periodontal surgery
- Patients with good oral hygiene maintenance.
- Patients with present or past systemic illnesses known to affect the outcomes of periodontal therapy
- Immunocompromised patients
- Patients taking medications that may interfere with periodontal therapy
- Pregnant patients
The study was explained to the patients, and informed consent was obtained. The study protocol was approved by the Institutional Ethical Committee of M.G. Vs KBH Dental College, Nashik.
Following the completion of Phase 1 therapy consisting of oral hygiene instructions and scaling and root planing, re-evaluation was performed after 4 weeks, [Flow Chart 1] after which ten patients were enrolled in the study and were randomly assigned to test group and control group by lottery method.
Preparation of Aloe vera gel
Aloe vera extract was obtained from the plant's leaf pulp as a thick glue-like gel.
Information about the advantages of Aloe vera gel was not given to the patients in order to avoid its psychological effect.
In both the groups, periodontal flap surgery was performed. Flaps were approximated with 3-0 nonabsorbable black silk sutures. Only the test group patients were asked to apply the Aloe vera gel supplied to them topically with their finger at the surgical site where the sutures were placed thrice daily for 1 week. They were instructed not to massage, and only apply the gel gently to the surgical site for 10 min [Figure 1].
|Figure 1: (a) Preoperative picture of test site, (b) immediate postoperative picture of test site, (c) preoperative picture of control site, (d) immediate postoperative picture of control site|
Click here to view
Postoperatively, all patients were prescribed with antimicrobial (amoxicillin, 500 mg, 8 hourly for 5 days) and nonsteroidal anti-inflammatory drugs (ibuprofen 400 mg + paracetamol 325 mg) twice daily for 3 days. The sutures were removed 1 week postoperatively. The surgical sites were gently cleansed with normal saline and betadine.
Postoperative healing was assessed using the Early Healing Index (EHI) [Table 1] after the 1st week and Healing Index (HI) [Table 2] after the 1st, 2nd, and 3rd weeks following therapy by a same surgeon.
All statistical tests were done using a statistical software package (version 20, SPSS, Inc., Chicago, IL, USA), and P ≤ 0.05 was considered statistically significant. To compare the mean values between groups, unpaired t-test for independent samples was applied.
| Results|| |
This study was of split-mouth design with two groups each having at least two interproximal surgical sites; 10 individuals were included in the study with a total of forty sites.
All patients completed the study (five males and five females, age range: 25–55 years). Overall, forty sites were studied for postoperative healing. Twenty sites were from the test group where Aloe vera gel was applied.
Better healing was observed in the test sites in comparison to the control sites in the 1st postoperative week as recorded by the EHI (P < 0.001) and HI (P = 0.01) [Figure 2]a and [Figure 2]b. However, there were no significant differences between the test and control sites in the 2nd (P = 0.12) and 3rd (P = 0.50) weeks [Figure 3]a, [Figure 3]b, [Figure 3]c, [Figure 3]d. Moreover, a significant improvement in healing scores was observed for the test and control sites from the 1st to 3rd postoperative week [Table 3].
|Figure 2: (a) Healing after postoperative 1st week in the control site, (b) healing after the postoperative 1st week in the test site|
Click here to view
|Figure 3: (a) Healing after the postoperative 2nd week in control site, (b) healing after the postoperative 3rd week in control site, (c) healing after the postoperative 2nd week in test site (d) healing after the postoperative 3rd week in test site|
Click here to view
|Table 3: Comparison of postoperative healing scores between the test and control groups|
Click here to view
| Discussion|| |
The aim of this study was to evaluate the effectiveness of fresh Aloe vera gel on postoperative healing following periodontal surgery in patients with chronic periodontitis. The result of this study demonstrated that application of fresh Aloe vera extract in the test group was effective in achieving better wound healing after 1 week (standard deviation [SD] = 0.90) as compared to the control group (SD = 0.60).
The results of the present study are in accordance with studies by Davis et al. who stated that wound healing with Aloe vera was due to increased blood supply; increased oxygenation, which stimulates fibroblast activity; and collagen proliferation. Davis et al. in in vitro and in vivo studies showed healing with fibroblast proliferation. Wound healing is achieved by means of growth factors such as gibberellins, auxin, and mannose phosphate, which are present in Aloe vera which bind to insulin-like growth factor receptor to improve healing.
More than 200 compounds are found in Aloe barbadensis, about 75 of which have biological activity. Aloe vera leaves contain a diverse array of compounds, including anthraquinones (e.g., aloe-emodin), anthrones and their glycosides (e.g., 10-(1, 5' anhydroglucosyl)-aloeemodin-9-anthrone, also known as aloin A and B), chromones, carbohydrates, proteins, glycoproteins, amino acids, organic acids, lipids, sugars, vitamins, and minerals. According to Aggarwal et al., 2011, Aloe vera inhibits the production of free oxygen radicals by activated polymorphonuclear leukocytes. Mannose-6-phosphate is a major structural constituent of Aloe vera. It is responsible for wound healing and is found to be accompanied by higher levels of hyaluronic acid and dermatan sulfate, which were suggested to stimulate collagen synthesis which in turn involved in scar formation during healing. Vitamin C present in Aloe vera is involved in collagen synthesis, which increases the concentration of oxygen at the wound site because of dilation of blood vessels. Aloe vera is also shown to provide relief from swelling and bleeding gums, acts as an antiseptic for pockets, and has antifungal activity against thrush. In addition, acemannan composed of a long chain of acetylated mannose is a complex carbohydrate present in Aloe vera which has the potential to activate macrophages and stimulate the release of fibrogenic cytokines that promote healing. Acemannan can also directly bind to growth factors that increase collagen cross-linking and accelerate wound contraction, leading to increased breaking strength of the scar tissue . Carboxypeptidase present in Aloe vera inactivates bradykinin and relieves pain., C-glucosyl chromone, an anti-inflammatory compound, found in Aloe vera gel has the potential to inhibit the cyclooxygenase pathway and reduce the production of prostaglandin E2 from arachidonic acid. Aloe vera also has an antioxidant action because of the presence of three aloesin derivatives, namely isorabaichromone, feruoylaloesin, and p-coumaroylalosin.
For adequate documentation of periodontal wound healing, two healing indices were used. The EHI not only differentiates different degrees of exposure but also records the amount of fibrin formation when complete closure is present. Early and uneventful healing is associated with no or minimal fibrin formation as this occurs when trauma to the surgical site has been reduced to a minimum.
Aloe vera also has pain-relieving properties on wounds. Boonyagul et al. noted a significant increase in its alkaline phosphatase activity, bone marrow stromal cell proliferation, bone sialoprotein expression and mineralization, as in vitro effect of acemannan and there was higher bone mineral density and faster bone healing in acemannan-treated groups in comparison to control group., Hence, further controlled clinical trials with larger sample size are needed in future to support the pain-relieving property as well as for periodontal regeneration of Aloe vera in periodontal surgeries.
The limitations of the study associated with the natural herbal product (Aloe vera) such as difficulty in standardization, titration, and assay cannot be ignored.
| Conclusion|| |
Within the limitations of this study, the application of fresh Aloe vera gel was effective in improving healing scores in the 1st postoperative week. Hence, Aloe vera is an effective and low-cost therapeutic agent for better periodontal wound healing.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Flemmig TF. Periodontitis. Ann Periodontal 1999;4:32-8.
Matthews DC, McCulloch CA. Evaluating patient perceptions as short-term outcomes of periodontal treatment: A comparison of surgical and non-surgical therapy. J Periodontol 1993;64:990-7.
Clark RA, editor. Wound repair. Overview and general considerations. In: The Molecular and Cellular Biology of Wound Repair. 2nd
ed.. New York: Plenum Press; 1996. p. 3-50.
Wikesjö UM, Crigger M, Nilvéus R, Selvig KA. Early healing events at the dentin-connective tissue interface. Light and transmission electron microscopy observations. J Periodontol 1991;62:5-14.
Griffin TJ, Cheung WS, Zavras AI, Damoulis PD. Postoperative complications following gingival augmentation procedures. J Periodontol 2006;77:2070-9.
Anderson LA. Concern regarding herbal toxicities: Case reports and counseling tips. Ann Pharmacother 1996;30:79-80.
Reynolds T, Dweck AC. Aloe vera
leaf gel: A review update. J Ethnopharmacol 1999;68:3-7.
Vogler BK, Ernst E. Aloe vera
: A systematic review of its clinical effectiveness. Br J Gen Pract 1999;49:823-8.
Wachtel H, Schenk G, Böhm S, Weng D, Zuhr O, Hürzeler MB. Microsurgical access flap and enamel matrix derivative for the treatment of periodontal intrabony defects: A controlled clinical study. J Clin Periodontol 2003;30:496-504.
Landry RG, Turnbull RS, Howley T. Effectiveness of benzydamine HCl in the treatment of periodontal postsurgical patients. Res Clin Forum 1988;10:105-18.
Davis RH, Leitner MG, Russo JM, Byrne ME. Wound healing. Oral and topical activity of Aloe vera
. J Am Podiatr Med Assoc 1989;79:559-62.
Davis RH, Donato JJ, Hartman GM, Haas RC. Anti-inflammatory and wound healing activity of a growth substance in Aloe vera
. J Am Podiatr Med Assoc 1994;84:77-81.
Gupta BM, Ahmed KM, Gupta R. Glycyrrhiza glabra (Medicinal Plant) Research: A Scientometric Assessment of Global Publication Output during 1997-2016. Pharmacogn J 2018;10.
Aggarwal BB, Prasad S, Reuter S, Kannappan R, Yadev VR, Park B, et al.
Identification of novel anti-inflammatory agents from ayurvedic medicine for prevention of chronic diseases: “reverse pharmacology” and “bedside to bench” approach. Curr Drug Targets 2011;12:1595-653.
Choonhakarn C, Busaracome P, Sripanidkulchai B, Sarakarn P. The efficacy of Aloe vera
gel in the treatment of oral lichen planus: A randomized controlled trial. Br J Dermatol 2008;158:573-7.
Ishii Y, Tanizawa H, Takino Y. Studies of Aloe
. III. Mechanism of cathartic effect. (2). Chem Pharm Bull (Tokyo) 1990;38:197-200.
Fujita K, Teradaira R, Nagatsu T. Bradykinase activity of Aloe
extract. Biochem Pharmacol 1976;25:205.
Bautista-Pérez R, Segura-Cobos D, Vázquez-Cruz B.In vitro
antibradykinin activity of Aloe barbadensis
gel. J Ethnopharmacol 2004;93:89-92.
Haller JS Jr. A drug for all seasons. Medical and pharmacological history of Aloe
. Bull N Y Acad Med 1990;66:647-59.
Hashemi SA, Madani SA, Abediankenari S. The review on properties of Aloe vera
in healing of cutaneous wounds. Biomed Res Int 2015;2015:714216.
Boonyagul S, Banlunara W, Sangvanich P, Thunyakitpisal P. Effect of acemannan, an extracted polysaccharide from Aloe vera
, on BMSCs proliferation, differentiation, extracellular matrix synthesis, mineralization, and bone formation in a tooth extraction model. Odontology 2014;102:310-7.
Rathod SR, Raj A, Sarda T, Maske S. Aloe vera
: A natural remedy. SRM J Res Dent Sci 2018;9:32.
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3]