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

doi:10.4103/jorr.jorr_14_19

ORIGINAL ARTICLE

Year : 2019 | Volume : 11 | 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

Correspondence Address:
Anuja D Hudwekar
Department of Periodontology and Implantology, MGV's KBH Dental College and Hospital, Nashik, Maharashtra
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/jorr.jorr_14_19

Abstract

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 1^st week and the Healing Index (HI) after the 1^st, 2^nd, 3^rd, and 4^th weeks.
Results: Better initial healing was observed in the test sites in comparison to the control sites in the 1^st postoperative week as recorded by the EHI and HI, whereas no significant differences were observed at the 2^nd, 3^rd, and 4^th weeks.
Conclusion: Application of Aloe vera extract was effective in significantly improving healing scores in the 1^st 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 2021 Jan 23];11:72-6. Available from: https://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.^[1] 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.^[2]

Healing of wound is a classical example of regeneration and repair.^[3] 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.^[4] 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.^[5]

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.^[6],[7],[8]

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.

Inclusion criteria

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.

Exclusion criteria

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
Smokers.

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.

Surgical procedure

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

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Postoperative care

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.

Data collection

Postoperative healing was assessed using the Early Healing Index (EHI) [Table 1]^[9] after the 1^st week and Healing Index (HI) [Table 2]^[10] after the 1^st, 2^nd, and 3^rd weeks following therapy by a same surgeon.

Table 1: Early Healing Index (Wachtel et al., 2003)

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Table 2: Healing Index by Landry et al. (1988)

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Statistical analysis

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 1^st 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 2^nd (P = 0.12) and 3^rd (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 1^st to 3^rd postoperative week [Table 3].

Figure 2: (a) Healing after postoperative 1^st week in the control site, (b) healing after the postoperative 1^st week in the test site

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Figure 3: (a) Healing after the postoperative 2^nd week in control site, (b) healing after the postoperative 3^rd week in control site, (c) healing after the postoperative 2^nd week in test site (d) healing after the postoperative 3^rd week in test site

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Table 3: Comparison of postoperative healing scores between the test and control groups

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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.^[11] 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.^[12] 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.^[13] According to Aggarwal et al., 2011, Aloe vera inhibits the production of free oxygen radicals by activated polymorphonuclear leukocytes.^[14] 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.^[15] 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.^[14] 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.^[16] 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 ^.[7] Carboxypeptidase present in Aloe vera inactivates bradykinin and relieves pain.^[17],[18] 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.^[19]

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.^[9]

Future prospect

Aloe vera also has pain-relieving properties on wounds.^[20] 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.^[21],[22] 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.

Limitation

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 1^st postoperative week. Hence, Aloe vera is an effective and low-cost therapeutic agent for better periodontal wound healing.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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