|Year : 2020 | Volume
| Issue : 4 | Page : 279-284
Herbal irrigants in primary teeth: A step toward green dentistry based on the wisdom of past
Archna Agnihotri1, Rosy Arora1, Urvashi Sharma1, Poonam Sood2
1 Department of Pediatric Dentistry, Dr HSJIDS, Panjab University, Chandigarh, India
2 Department of Preventive Dentistry, Dr HSJIDS, Panjab University, Chandigarh, India
|Date of Submission||06-Jun-2020|
|Date of Decision||07-Jul-2020|
|Date of Acceptance||15-Oct-2020|
|Date of Web Publication||16-Dec-2020|
Department of Pediatric Dentistry, Dr HSJIDS, Panjab University, Chandigarh - 160 025
Source of Support: None, Conflict of Interest: None
A wide plethora of chemical endodontic irrigants are used to achieve the desired results in terms of disinfection and removal of debris besides mechanical means. However, their detrimental properties such as allergic potential, cytotoxicity, antimicrobial resistance, and safety concerns have intrigued researchers over the years to look for safer options. During the past decade, the number of studies has increased utilizing herbs as irrigating solutions. This literature review was conducted to summarize the existing knowledge and provide a comprehensive review of clinical trials on herbal irrigating solutions in pediatric dental patients. An exhaustive literature search was performed in the indexed databases electronically for publications in peer reviewed scientific journals to find the relevant clinical studies evaluating efficacy of herbal root canal irrigants employed in primary teeth.
Keywords: Herbal, irrigants, primary teeth, root canal
|How to cite this article:|
Agnihotri A, Arora R, Sharma U, Sood P. Herbal irrigants in primary teeth: A step toward green dentistry based on the wisdom of past. J Indian Assoc Public Health Dent 2020;18:279-84
|How to cite this URL:|
Agnihotri A, Arora R, Sharma U, Sood P. Herbal irrigants in primary teeth: A step toward green dentistry based on the wisdom of past. J Indian Assoc Public Health Dent [serial online] 2020 [cited 2021 Apr 11];18:279-84. Available from: https://www.jiaphd.org/text.asp?2020/18/4/279/303632
| Introduction|| |
The primary teeth are of utmost importance to a child's dentofacial growth and development. Not only do they play a role in the maintenance of speech and mastication but also they are very significant in guiding the eruption of permanent dentition. However, they become involved with dental caries, frequently mandating root canal treatment. The successful outcome of root canal therapy depends largely on the thorough disinfection of the root canal system. Based on this objective, the goal is to completely eradicate or considerably minimize the microorganisms and their toxic products from the root canal before obturation.
Evidence has shown that necrotic tissues, microorganisms, and their by-products remained inside the dentin tubules, canal ramifications, and resorption craters which were inaccessible to root canal instruments resulting in persistent periradicular inflammation. Thus, complete chemomechanical debridement is essential using clinically effective and biocompatible irrigants which can also help in dissolving the organic debris., Numerous studies have been done to determine the antimicrobial effects of various endodontic irrigants. The ideal irrigants should be bactericidal, have the ability to dissolve necrotic tissue, remove the smear layer besides lubricating the canal, and should not be irritating to healthy tissues. Pediatric dentists have to choose appropriately while performing root canal therapy for children. Evidence suggests significant morphological differences between the permanent and primary teeth. Still, the findings obtained from permanent teeth have been assumed to apply to primary teeth.,,
Anatomic variations in primary teeth such as curved and tortuous root canals, their close proximity to succedaneous tooth buds alongwith the uncertainy about the effects of root canal irrigants make the treatment in primary teeth altoghther a challenging task. It is important to evaluate treatments specifically for primary dentin since it cannot be assumed that permanent and primary dentin will respond to treatment in the same way. In clinical practice, various root canal irrigating solutions have been proposed for primary teeth such as sodium hypochlorite, chlorhexidine gluconate, ethylenediaminetetraacetic acid, citric acid, hydrogen peroxide, and others. However, due to their low safety profile, chemical irrigants cannot be used as copiously as in permanent dentition. During the past decade, there has been a surge in the clinical trials using herbal irrigants due to their high safety profile besides having physiologically beneficial active constituents that have curative, antioxidant, anti-inflammatory, and radical scavenging properties. Several in vitro and in vivo studies have been done to establish the efficacy of herbal root canal irrigants in search of an ideal agent for use in pediatric patients.
Till now, a perusal of clinical review data is available regarding the use of herbal root canal irrigants for adult population and intracanal irrigants in primary dentition that has been systematically reviewed, but data for herbal irrigating solutions for pediatric dental patients have not been compiled yet which makes this attempt to summarize the existing knowledge and provide a comprehensive review of clinical efficacy of herbal canal irrigants in randomized clinical trials in primary teeth implausible. This review aims at providing a comprehensive review of available literature to assess the findings on the clinical efficacy of herbal root canal irrigating solutions employed in the primary dentition.
| Materials and Methods|| |
The literature review was started with a defined background to review the studies involving interventions using herbal endodontic irrigants for disinfection and debridement of root canals in primary teeth for a population of up to 12 years.
- Randomized controlled clinical trials published in peer-reviewed scientific journals in the English language from 1985 to April 2020
- In vivo studies
- Studies on children up to 12 years
- Studies only involving primary teeth.
Population, intervention, control, and outcomes criteria were used to select studies in children up to the age of 12 years (Population) studied for herbal root canal irrigants in primary teeth (Interventions) done to assess their comparative efficacy (Control irrigant) by the means of clinical, radiographic, or microbiological results (Outcome).
Indexed databases PubMed (National Library of Medicine), Cochrane Database Library, and Google Scholar were electronically searched for publications in the English literature in peer-reviewed scientific journals up to and including April 2020.
Hand search of all bibliographies of downloaded articles was done. The titles and abstracts of identified studies using the above-described search protocol were independently screened by two blinded authors (AA and RA); any disagreements were resolved via discussion. The selected studies were downloaded in full texts and were read independently. The two reviewers performed the data extraction independently, and again, the disagreements were solved via discussion. Studies evaluating the herbal irrigating solutions in primary teeth with clinical, radiographic, and microbiological results were considered eligible. The data collected was tabulated.
| Results|| |
The electronic databases and hand-searched journal searches identified a total of 744 potential articles and after screening for duplication, 731 were left. After reviewing the titles and abstracts, 720 articles did not meet the selection criteria and were discarded. The full text of the remaining 11 articles was downloaded, screened, and assessed for eligibility. Six studies were identified for inclusion in the review. The flow chart [Table 1] depicts the number of abstracts retrieved, excluded, and included papers at different stages of search process. It is possible that some paper might have been missed due to limitations inherent in the process, but majority of the papers with quality methodology were retrieved.
The six studies found relevant for the review were randomized controlled trials published between 2011 and 2019. The follow-up for all the trials was done through immediate assessment. All the results were measured in colony-forming units (CFU's). [Table 2] and [Table 3] describe the characteristics and results of clinical trials.
| Discussion|| |
The sole aim of any therapy is to provide maximum benefit to the patient with minimal harm and discomfort. In case of deciduous teeth, because of the presence of thin dentinal walls, extensive mechanical preparation is not desirable; therefore, root canal irrigating solutions perform a major role in debridement of the root canal system. Hence, it becomes particularly important for a pediatric dentist to adopt a holistic approach so as to perform a high level of quality treatment to ensure long-term successful clinical results. Elimination of microorganisms from infected root canals of primary teeth is an arduous task. None of the available irrigating solution alone is known to provide all the ideal requirements. Excellent tissue solvent and antimicrobial properties make sodium hypochlorite the most widely recommended endodontic irrigant when used concentrations between 0.5% and 5.25%, but serious damage caused by the accidental extrusion into periradicular tissues even in small amounts puts a question mark on its safety profile.,,, With the background of having a rich heritage of medicinal plants and herbs which have been used since the time immemorial, these medicinal plants and herbs rich in phytochemicals now are being used as an important constituent of endodontic medicine. Various in vitro and in vivo studies have been done using herbal irrigants in primary teeth This article aims at providing a comprehensive review of the available clinical trials on herbal irrigants in primary teeth and bridging the gaps in clinically relevant research activities.
Three studies assessed propolis extracts in different concentrations and solvents (4% in dimethylsiloxane, 25% aqueous extract of propolis, and 11% ethanolic extract of propolis) and 0.9% saline solution.,, In all of these studies, propolis showed an antimicrobial effect but that was only comparable to that of calcium hydroxide and saline. Another study comparing the efficacy of Triphala (in dimethylsiloxane) found it to be slightly more potent as compared to sterile saline in the reduction of microbial count. Chandwani et al. compared the antimicrobial efficacy between 7% Morinda citrifolia juice and 1% NaOCl and no statistical difference was found between the two test irrigants in reduction of endodontic microflora. Shingare and Chaugule compared 12.5% ethanolic extract of Miswak with 3% NaOCl and no statistical intergroup differences were found in the mean reduction of microbial count. Prabhakar et al. compared 4% aqueous extract of Ocimum sanctum (tulsi) with saline and found statistically significant difference against periapical pathogens isolated from the root canals.
The literature is sparse regarding the use of irrigating solutions in primary teeth but still increasing, particularly in herbal products as endodontic irrigants. The article reviewed the potential herbal irrigants that could substitute the conventional chemical endodontic irrigants in pediatric clinical practice. Available literature and studies demonstrate the efficacy of each irrigant under consideration and none of them completely fit into the prerequisites of an ideal endodontic irrigant. In these clinical trials Tulsi, Miswak, and M. citrifolia juice proved to be as efficacious as NaOCl at different concentrations as also has been proved in various in vitro and ex vivo studies.,, Triphala and propolis extracts proved to be only marginally better than the normal saline as compared to in vitro and in vivo studies in permanent teeth, wherein their antimicrobial efficacy was found to be comparable to different concentrations (2.5%–5%) of NaOCl and significantly better than saline,,, The propagation of microrganisms into the tortuous canal system in primary teeth including lumen, accessory canals, dentinal tubules, apical delta, apical foramen and further into periapical biofilms could be the reason for their lower efficacy in primary teeth clinical trials.[25-27] After critically assessing the studies with regard to evidence quality, the studies had only immediate follow-ups and dropouts, the sample size calculation was not mentioned, and also any reports of side effects were not addressed. One study had inadequate reporting of data. Manual counting of the CFU's in some studies were few of the other limitations.
Considering the safety, low toxicity, antibacterial, and antioxidant properties, these herbs can be advocated as root canal irrigants in endodontic treatment of primary teeth and also in patients having history of allergic reactions. Other herbal irrigants such as Azadirachta indica, Allium sativum, green tea, and turmeric could also be incorporated for further clinical trials to substantiate and evaluate their clinical efficacy as proved by in vitro studies., Few limitations of this scoping review process were that it could only provide an overview of the literature pertaining to the use of herbal root canal irrigants in primary dentition and the research data was not quantitatively assessed and combined. The review could not arrive at a discrete answer regarding an ideal herbal root canal irrigant. However, this information could help provide the clinicians a road map to use safer alternatives to chemical irrigants in pediatric dental patients and also a baseline to conduct further trials using similar or a combination of herbal irrigants in a larger sample size and with long-term follow-ups.
| Conclusion|| |
Herbs such as Tulsi, Miswak, and M. citrifolia definitely have a potential to replace the chemical irrigants in pediatric dental patients but keeping view the paucity of comparative/controlled studies; determining the most efficient herbal intracanal irrigant presently is not possible. Although, these could be used as routine root canal irrigants and also as an adjunct to chemical irrigants, thereby lowering their dose and toxicity in resistant or failed root canal treatment cases. Further controlled studies investigating the combination of herbs and evaluating their synergistic action could lead us to the path of herbalism in dentistry and promote wellness in a real sense.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Mistry KS, Shah S. Review on common root canal irrigants. J Dent Sci 2011;2:27-31.
Gondim JO, Avaca-Crusca JS, Valentini SR, Zanelli CF, Spolidorio DM, Giro EM. Effect of a calcium hydroxide/chlorhexidine paste as intracanal dressing in human primary teeth with necrotic pulp against Porphyromonas gingivalis
and Enterococcus faecalis
. Int J Paediatr Dent 2012;22:116-24.
Ito IY, Junior FM, Paula-Silva FW, da Silva LA, Leonardo MR, Nelson-Filho P. Microbial culture and checkerboard DNA-DNA hybridization assessment of bacteria in root canals of primary teeth pre- and post-endodontic therapy with a calcium hydroxide/chlorhexidine paste. Int J Paediatr Dent 2011;21:353-60.
Kaur R, Singh R, Sethi K, Garg S, Miglani S. Review article irrigating solutions in Pediatric Dentistry: Literature review and update. J Adv Med Dent Sci 2014;2:104-15.
Sumikawa DA, Marshall GW, Gee L, Marshall SJ. Microstructure of primary tooth dentin. Pediatr Dent 1999;21:439-44.
Al-Kilani MG, Whitworth JM, Dummer PM. Preliminary in vitro
evaluation of Carisolv as a root canal irrigant. Int Endod J 2003;36:433-40.
Holan G, Fuks AB. A comparison of pulpectomies using ZOE and KRI paste in primary molars: A retrospective study. Pediatr Dent 1993;15:403-7.
Singhal P, Das UM, Vishwanathan D, Singhal A. Carisolv as an endodontic irrigant in deciduous teeth: An SEM study. Indian J Dent Res 2012;23:120-1. [Full text]
Peter's OA, Peters CI. Cleaning and Shaping of the root canal system. In: Hargreaves K, Cohen S, editors. Cohen's Pathways of Pulp. 10th
ed.. St. Louis.: Elsevier Mosby Publication; 2011. p. 283-341.
Chandwani M, Mittal R, Chandak S, Pimpale J. Effectiveness of Morinda citrifolia
juice as an intracanal irrigant in deciduous molars: An in vivo
study. Dent Res J (Isfahan) 2017;14:246-51.
Jolly M, Singh N, Rathore M, Tandon S, Banerjee M. Propolis and commonly used intracanal irrigants: Comparative evaluation of antimicrobial potential. J Clin Pediatr Dent 2013;37:243-9.
Verma MK, Pandey RK, Khanna R, Agarwal J. The antimicrobial effectiveness of 25% propolis extract in root canal irrigation of primary teeth. J Indian Soc Pedod Prev Dent 2014;32:120-4.
] [Full text]
Subramanyam D, Somasundaram S. Evaluation of Antimicrobial effect of Triphala versus conventional root canal irrigants in primary teeth An in vivo
study. Res J Pharm Tech 2019;12:655-9.
Shingare P, Chaugule V. Comparative evaluation of antimicrobial activity of miswak, propolis, sodium hypochlorite and saline as root canal irrigants by microbial culturing and quantification in chronically exposed primary teeth. Germs 2011;1:12-21.
Prabhakar AR, Krishna Murthy VV, Vallu Yavagal C. Ocimum sanctum
as an intracanal irrigant in contemporary paediatric endodontics – An in vivo
study. Int J Oral Health Med Res 2015;2:6-9.
Sjögren U, Figdor D, Persson S, Sundqvist G. Influence of infection at the time of root filling on the outcome of endodontic treatment of teeth with apical periodontitis. Int Endod J 1997;30:297-306.
Zehnder M, Kosicki D, Luder H, Sener B, Waltimo T. Tissue-dissolving capacity and antibacterial effect of buffered and unbuffered hypochlorite solutions. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2002;94:756-62.
Hülsmann M, Hahn W. Complications during root canal irrigation Literature review and case reports. Int Endod J 2000;33:186-93.
Gernhardt CR, Eppendorf K, Kozlowski A, Brandt M. Toxicity of concentrated sodium hypochlorite used as an endodontic irrigant. Int Endod J 2004;37:272-80.
Choudhary E, Indushekar KR, Saraf BG, Sheoran N, Sardana D, Shekhar A. Exploring the role of Morinda citrifolia
and Triphala juice in root canal irrigation: An ex vivo
study. J Conserv Dent 2018;21:443-9.
] [Full text]
Divia AR, Nair MG, Varughese JM, Kurien S. A comparative evaluation of Morinda citrifolia
, green tea polyphenols, and Triphala with 5% sodium hypochlorite as an endodontic irrigant against Enterococcus faecalis
: An in vitro
study. Dent Res J (Isfahan) 2018;15:117-22.
Chandrappa PM, Dupper A, Tripathi P, Arroju R, Sharma P, Sulochana K. Antimicrobial activity of herbal medicines (tulsi extract, neem extract) and chlorhexidine against Enterococcus faecalis
in Endodontics: An in vitro
study. J Int Soc Prev Community Dent 2015;5 (Suppl 2):S89-92.
Garg P, Tyagi SP, Sinha DJ, Singh UP, Malik V, Maccune ER. Comparison of antimicrobial efficacy of propolis, Morinda citrifolia
, Azadirachta indica
, triphala, green tea polyphenols and 5.25% sodium hypochlorite against Enterococcus fecalis
biofilm. Saudi Endod J 2014;4:122-7. [Full text]
Satti P, Kakarla P, Jogendra Avula SS, Muppa R, Kiran Rompicharla SV, Biswas S. Indigenous irrigants as potent antimicrobials in endodontic treatment: An in vitro
study. J Indian Soc Pedod Prev Dent 2019;37:275-81.
] [Full text]
Molander A, Reit C, Dahlén G, Kvist T. Microbiological status of root-filled teeth with apical periodontitis. Int Endod J 1998;31:1-7.
Thomas S, Asokan S, John B, Priya G, Kumar S. Comparison of antimicrobial efficacy of diode laser, triphala, and sodium hypochlorite in primary root canals: A randomized controlled trial. Int J Clin Pediatr Dent 2017;10:14-7.
Sowjanyaa J, Thomas T, Chandana CS. Comparative evaluation of the efficacy of smear layer removal by ethylenediaminetetraacetic acid, Triphala, and German chamomile as irrigants A scanning electron microscopy study. J Adv Pharm Edu Res 2017;7:261-71.
Gradisar H, Pristovsek P, Plaper A, Jerala R. Green tea catechins inhibit bacterial DNA gyrase by interaction with its ATP binding site. J Med Chem 2007;50:264-71.
Chaturvedi TP. Uses of turmeric in dentistry: An update. Indian J Dent Res 2009;20:107-9.
] [Full text]
[Table 1], [Table 2], [Table 3]