|Year : 2012 | Volume
| Issue : 2 | Page : 84-89
Effect of locally delivered aloe vera gel as an adjunct to scaling and root planing in the treatment of chronic periodontitis: A clinical study
Harjit Kaur Virdi, Sanjeev Jain, Shivani Sharma
Department of Periodontology and Oral Implantology, Guru Nanak Dev Dental College and Research Institute, Sunam, Punjab, India
|Date of Submission||16-Jun-2012|
|Date of Acceptance||21-Aug-2012|
|Date of Web Publication||24-Jan-2013|
Harjit Kaur Virdi
Department of Periodontology and Oral Implantology, Guru Nanak Dev Dental College and Research Institute, Sunam, Punjab
Source of Support: None, Conflict of Interest: None
Objective: The aim of this study was to evaluate the effect of aloe vera gel as an adjunct to scaling and root planing (SRP) in the management of chronic periodontitis.
Materials and Methods: The effect of aloe vera on reduction of plaque, gingivitis, and periodontitis was evaluated in a randomized, single-blind, split-mouth study. Twenty patients with chronic periodontitis having 5 mm periodontal pockets bilaterally at least in one site were included in the study. On one side, SRP was done and on the contralateral side along with SRP pure aloe vera gel was applied in the periodontal pockets at the baseline and after 1 and 2 weeks. Probing pocket depth, gingival index (GI; and plaque index (PI; were noted at the baseline and after 6 weeks.
Results: There was a significant improvement in the pocket depth and the GI readings after 6 weeks in both the groups (paired t-test). On comparing, the SRP-ALOE group showed significantly better results than SRP alone ( P < 0.0001) (ANOVA test). In the PI though the significant improvement was there in both the groups, the difference between the groups was not significant ( P > 0.1771).
Conclusion: Results encourage the use of aloe vera in the treatment of periodontitis.
Keywords: Aloe vera, dental plaque, gingivitis, periodontitis
|How to cite this article:|
Virdi HK, Jain S, Sharma S. Effect of locally delivered aloe vera gel as an adjunct to scaling and root planing in the treatment of chronic periodontitis: A clinical study. Indian J Oral Sci 2012;3:84-9
|How to cite this URL:|
Virdi HK, Jain S, Sharma S. Effect of locally delivered aloe vera gel as an adjunct to scaling and root planing in the treatment of chronic periodontitis: A clinical study. Indian J Oral Sci [serial online] 2012 [cited 2017 May 25];3:84-9. Available from: http://www.indjos.com/text.asp?2012/3/2/84/106460
| Introduction|| |
The periodontal diseases are among the most common of chronic diseases to affect the mankind. A buildup of plaque related to poor oral hygiene is one of the main causes of periodontal disease. Mechanical plaque control is the most effective method of controlling plaque and gingivitis. However, the inability of normal adult population to perform adequate tooth brushing and other oral hygiene measures has led to the search for chemotherapeutic agents to improve plaque control. Various chemotherapeutic agents used are chlorhexidine, quaternary compounds, triclosan, etc., Although these agents show remarkable efficacy in improving periodontal health but due to undesirable side effects such as tooth staining, taste alteration, and cost of these substances, the use of natural products has increased recently and could be of benefit to low socioeconomic communities. 
Among the various currently available herbal agents, Aloe is considered to be a promising and high-ranking agent as an all-purpose herbal plant. Aloe belongs to liliaceae family. There are about 400 species of aloe, but only five can be used as medicine. Among all Aloe barbadensis, also known as aloe vera, has the greatest medicinal value. The word Aloe is derived from the Arabic word "ALLOEH", which means shiny and bitter and the word VERA is a latin word meaning true because in ancient times this particular species was regarded as the most effective for general therapeutic and medicinal uses.  The leaves of aloe vera contain two major pharmacological components. One is a bitter yellow sap, which is extracted from specific areas of inner leaf. This substance is known to have a laxative effect so also referred as "Latex". The other major component is gel which is clear, semisolid substance that makes up the parenchyma. This gel has been used for centuries for skin afflictions and wounds. 
The history of use of aloe vera dates back to a few thousand years. A Sumerian clay tablet from 2200 BC was the first document to include aloe among the plants of healing power. Its modern use was first recognized in 1934 by Dr. C.E. Collins where several cases of roentgen dermatitis, the ulcerated skin lesions, were treated with aloe vera leaves. In 1937, Dr. J.E. Crew presented a wider use of aloe vera in treating chronic ulcers, eczema, burns, sunburns, poison ivy, and minor injuries. In 1959, the Food and Drug Administration admitted that aloe ointment actually did regenerate skin tissue. Since then topical use of aloe vera is common as doctors use it to treat burns and cut wounds, alopecia, and acne vulgaris and there is evidence that aloe vera may be beneficial in cases of arthritis, digestive system problems, diabetic patients, cancer prevention, HIV infection, and hyper susceptibility illness such as asthma, measles, rhinitis, etc. ,
Although the medical uses of aloe vera have been reported, not much literature is available regarding its use in the field of dentistry. A study, conducted by Villalobos et al. in 2001, evaluating clinical effects of aloe vera showed a significant reduction of gingivitis and plaque accumulation after use of a mouth rinse containing this natural product.  The antimicrobial effect of a dentifrice containing aloe vera has been demonstrated in an in vitro study conducted by Lee et al. in 2004, in which this phytotherapic agent inhibited the growth of diverse oral microorganisms, such as Streptococcus mutans, Streptococcus sanguis, Actinomyces viscosus, and Candida albicans.  de Oliveira et al. in 2008 conducted a double-blind clinical study in humans to evaluate the effect of a dentifrice containing aloe vera on plaque and gingivitis and found that there was a significant reduction in plaque and gingivitis. 
In the previous studies, the effect of aloe vera only on the plaque and gingivitis control was observed. The purpose of this study was to evaluate the efficacy of aloe vera as an adjunct to scaling and root planing (SRP) in patients with chronic periodontitis.
| Materials and Methods|| |
Twenty patients (11 males and 9 females) in the age group of 35-65 years (mean age, 47.67 ± 10.021) were included in a randomized, single-blind, split-mouth study. A split-mouth design was planned so as to reduce the error variance of the experiment. The patients selected were referred to the Department of Periodontology and Oral Implantology for treatment of chronic periodontitis. Patients who were current smokers, pregnant, had systemic diseases such as diabetes had taken systemic or topical antibiotic therapy or the over-the-counter antioxidants such as vitamin C, vitamin E, or β-carotene within the last 3 months or who had undergone periodontal therapy within last 3 months were excluded from the study. All the selected patients exhibited the clinical signs of moderate-advanced periodontitis including about 5 mm pockets bilaterally at least at one site. All the screened participants were informed about the nature of the study and a written consent was obtained.
The ethical committee of the institution had approved the designed protocol. The selected treatment sites were randomly divided into two groups by a lottery method.
It consisted of periodontal pockets on one side of the jaw in which only scaling and root planing were done (SRP group).
It consisted of periodontal pockets on the contra lateral side in which SRP was followed by application of aloe vera gel. Full mouth scaling and root planning were done with hand instruments. Only two contralateral sites in the posterior teeth were selected per volunteer for the study. After SRP, in group II aloe vera gel was applied by a syringe inserted up to the base of the pocket (SRP-ALOE group). Aloe vera gel used in this study was CURAGEL prepared by Cure Pharma. It is the pure aloe vera extract obtained from the centre of the leaf, processed to eliminate the toxins and having 2% sodium benzoate as a preservative. Aloe vera gel was reapplied after the first week and second week in the selected site just at the entrance of the periodontal pocket. The syringe was not inserted up to the base while reapplication so as not to disturb healing. All treatments were performed by an experienced periodontal specialist.
No dietary restrictions were imposed during or after the treatment. All the participants were instructed to use Colgate dental cream for tooth brushing, and no chemotherapeutic agents were permitted.
The following clinical parameters were recorded on a case report form and were double entered into a computer: Probing pocket depth, gingival index (GI): Loe and Sillness (1967), plaque index (PI): Turesky-Gilmore-Glickman (1970) modification of Quigley-Hein index. Parameters were recorded at the baseline and 6 weeks after the application. Clinical parameters were recorded by a single standardized trained examiner blinded to the treatment. In addition, the patients were also examined for any adverse reactions.
After completion of the clinical trial, data obtained from the sites were computed and put to statistical analysis. Site-based analysis was performed using parameter tests for the comparison between SRP and SRP + aloe vera groups for outcome variables under study. For each treatment group, the mean values for the probing pocket depth [Table 1], gingival index [Table 2], and plaque index [Table 3] were calculated at the baseline and after 6 weeks. Statistical analysis was obtained on these values. Paired t-test for difference within the group and ANOVA for difference between the groups were performed.
| Results|| |
All the treatment groups showed significant improvements in probing pocket depth, GI, and PI values over a period of 6 weeks. None of the patients showed any adverse reaction.
Probing pocket depth
At baseline, pocket depth values [Table 1] for the SRP and SRP-ALOE group were 5.887 ± 1.620 and 5.975 ± 1.392, respectively. There was not any significant difference between both the groups at the baseline (P = 0.8548).
After 6 weeks, in SRP group there was a statistically significant decrease in pocket depth values from 5.887 ± 1.620 to 4.213 ± 1.283 (P = 0.0008). In the SRP-ALOE group, there was also a statistically significant decrease in the pocket depth values from 5.975 ± 1.392 to 2.488 ± 0.582 (P < 0.0001). The intergroup comparison showed statistically significant improvement in the SRP-ALOE group as compared to SRP alone [Figure 1].
At baseline, GI values [Table 2] for the SRP and SRP-ALOE group were: 2.58 ± 0.251 and 2.50 ± 0.353, respectively. There was not any significant difference between both the groups at the baseline (P = 0. 414).
After 6 weeks, in both the SRP and SRP-ALOE group there was statistically significant improvement in GI values from 2.58 ± 0.251 to 1.375 ± 0.343 (P < 0.0001) and from 2.50 ± 0.353 to 0.55 ± 0.305 (P < 0.0001), respectively. When an intergroup comparison was made, it was observed that there was statistically significant improvement in GI in the SRP-ALOE group as compared to SRP alone ( P < 0.0001) [Figure 2].
At baseline, plaque index values [Table 3] for the SRP and SRP-ALOE group were 3.825 ± 0.609 and 3.926 ± 0.687, respectively. There was not any significant difference between both the groups at the baseline ( P = 0.6256).
After 6 weeks, in the SRP group there was significant improvement in PI values from 3.835 ± 0.609 to 1.475 ± 0.307 ( P < 0.001). Similarly with the SRP-ALOE group, there was statistically significant difference from 3.926 ± 0.687 to 1.325 ± 0.379 ( P < 0.001). In an intergroup comparison though the SRP-ALOE group showed slightly better results than the SRP group the difference was not significant ( P > 0.1771) [Figure 3].
| Discussion|| |
Aloe vera is a plant of amazing medicinal properties. The medicinal value of the plant lies in a gel-like pulp obtained on peeling the leaves which is thought to contain certain substances which account for its remarkable healing, anti-inflammatory, and antiseptic properties. These substances include lignins, saponins, vitamins, minerals, enzymes, amino acids, anthroquinones, etc. , Lignins are the cellulose-based substances which have the capacity to penetrate the tissue and carry elements with it, and saponins are the glycosides that promote cleansing and provide an antiseptic quality. Vitamins include Vit A which is necessary for integrity of epithelial cells, Vit C which helps in connective tissue regeneration (collagen synthesis), and Vit E which is an antioxidant and neutralises free radicals by donating one of their electrons, ending the electron stealing reaction. The antioxidant nutrient, however, does not become a free radical by donating an electron because they are stable in either form. It also contains minerals that increase tensile strength of wound, so helpful in early wound healing; anthroquinones which are similar to alkaloids produce analgesia and have healing, antibacterial, antiviral, and antifungal properties. Sugars such as polymannose, glucose, and fructose which have immune modulating and anti-inflammatory actions and amino acids that are the building blocks for repair and regeneration of traumatized tissue are also found in the aloe vera gel. Thus along with the healing, anti-inflammatory, and antiseptic properties, it is bactericidal, fungicidal, and virucidal.  The remarkable healing property of aloe vera was observed by Davis et al. in 1989 who noted that aloe vera is effective by both oral and topical routes of administration and aloe vera gel improved wound healing by increasing blood supply, which increased oxygenation as a result.  It has a positive influence on the collagen content and stability in a wound and therefore, a beneficial role in wound healing.  Yagi et al. in 2002 in a study found that three aloesin derivatives from aloe (namely isorabaichromione, feruloylaloesin, and p-coumaroylaloesin) have potent-free radical and superoxide anion scavenging properties.  It was found that aloesin compounds inhibited cyclooxygenase-2 (COX-2) and thromboxane (T X ) A 2 synthase, which explains the healing effects of aloe vera. , They suggested that both specific glycoproteins and aloesin-related compounds played an important role in the anti-inflammatory activity of gel from aloe vera leaves. Oral activity of aloe vera is also dependent on the presence of anthroquinones.  All these constituents may be effecting the healing after periodontal therapy by their effects at the cellular level. Its role in the treatment of Lichen planus  and Aphthous stomatitis  has also been reported.
Aloe vera is a natural product contained in herbal dentifrices with commercial appeal for the control of plaque and gingivitis. Despite its commercial use, this phytotherapic agent does not have sufficient data to support its antigingivitis and antiplaque claims. Therefore, this study was conducted to evaluate the efficacy of aloe vera as an adjunct to SRP in patients with periodontitis and to evaluate the changes occurring in the periodontium which were assessed through clinical parameters; probing pocket depth, GI, PI over a period of 6 weeks. After the first application of the gel at the baseline, reapplications were done after first week and second week so as to maintain the concentration of the gel in the treatment site as data regarding the substantivity of aloe vera gel is not available. Perinetti et al. in their study also gave four repeated applications of three subgingival gels separated by 7 days.  The time period for the study was taken as 6 weeks. According to Badersten et al., the assessment after SRP is generally made not less than 1-3 months.  The study design has been used in numerous investigations and can be described as an established method. , One shortcoming of this study is the short sample size. However, the sample size was found to be sufficient when power calculations (90%) were made prior to the study. It was observed that in both the groups, there was significant improvement in pocket depth, GI, and PI over a 6-week period. When an intergroup comparison was done, it was observed that the aloe vera + SRP group showed significantly better results than SRP alone in probing pocket depth [Table 1] and GI [Table 2], but there was no statistically significant difference between both groups regarding the PI values [Table 3].
The significant improvement in pocket reduction in the SRP-ALOE group may be attributed to the remarkable healing and anti-inflammatory properties of aloe vera due to the presence of vitamins, anthroquinones, glycoproteins, minerals, and amino acids. Similar results were also reported by Sudworth in 1997 who found aloe vera to be a powerful antiseptic in gum pockets.  Barrantes and Guinea in 2003 evaluated the effects of aloe vera gel constituents on the activity of microbial and human metalloproteinases and found that a collagenase from Clostridium histolyticum was dose dependently inhibited by the aloe vera gel and an active aloe vera gel fraction containing phenolics and aloins.  They also suggested that due to some chemical structural similarity between aloins and tetracyclines, aloe derivatives could inhibit the metallomatrix proteinases through a mechanism similar to that of inhibitory tetracyclines such as doxycycline. Similarly for GI, the significant difference may be due to additional anti-inflammatory and antiseptic qualities of aloe vera.  de Oliveira et al. (2008)  also reported significant reduction in plaque and gingivitis with use of dentifrice containing aloe vera. Dilip et al. demonstrated that aloe vera was as effective as two commercially popular toothpastes against Candida albicans, Streptococcus mutans, Lactobacillus acidophilus, Enterococcus faecalis, Prevotella intermedia, and Peptostreptococcus anaerobius. 
In this study, there was also a significant decrease in PI values in both the groups, i.e. for SRP and SRP + ALOE groups. In intergroup comparison, the SRP + ALOE group was better than the SRP group though the difference was not statistically significant ( P = 0.1771). de Oliveira et al. (2008)  in an in vivo study also reported that the dentifrice containing aloe vera did not show any additional effect on plaque control compared to the fluoridated dentifrice. In contrast, Lee et al. (2004)  reported an inhibitory effect of aloe vera against microorganisms from supragingival biofilm in an in vitro study.
All these findings encourage the use of aloe vera in the treatment of periodontal problems. If its real benefits are confirmed, the use of aloe veera should be advantageous in cases where patients have little motor skills and tooth brushing is compromised. Moore used aloe vera gel extensively in his patients and stated that the M and M's of aloe vera are not malarkey, magic, or a myth but that it is truly a miraculous plant, which should be included in our medicines too. 
| Conclusion|| |
In conclusion, the results presented in this study suggest that the aloe vera gel is effective in the treatment of chronic periodontitis when used as an adjunct to scaling and root planning. It can become an important part of the preventive and therapeutic treatments available for the periodontal diseases. However, due to the limited patient number in this study and a shorter time period further research based on long-term studies with larger number of patients and microbial studies is required in this field.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3]