INTRODUCTION:

“Aloe Vera” – the term Aloe is derived from the Arabic word ”alloeh” which means shiny and bitter while “Vera” from Latin word which means true.[1] Its history dates back to 1500 BC. It was reported that Alexander the great conquered the Island of Socotra in the Red Sea, has it had abundant Aloe fields so as to help his troops from healing of battle wounds. The Egyptians called Aloe Vera as the plant of immortality. Aloe Vera (Aloe barbadensis), belongs to the Liliaceae family. It is a shrub which is perennial, xerophytic, arborescent succulent. It mainly grows in the dry areas of Africa, Asia, Europe, and America. In India it is scattered in the wild, along the southern coast including Rajasthan, Andhra Pradesh, Gujarat, Maharashtra and Tamil Nadu. [2]

Dr. C.E. Collins recognized its modern use first in radiation burns in the year 1934 [3]. At present, Aloe Vera is used in various oral diseases like gingivitis, denture sore mouth [4], herpetic stomatitis,[5] oral lichen planus,[6] minor recurrent aphthous ulcer,[7] leukoplakia, and oral submucous fibrosis[8,9]. This review will deal with the recent advances in the role of Aloe Vera in oral health.

COMPOSITION:

Aloe Vera is composed of about 75 potentially active constituents: vitamins,enzymes, minerals, sugars, lignin, saponins, salicylic acids, and amino acids[10].The following table summarizes its important constituents.[11]

PHARMACOLOGICAL PROPERTIES:

Wound healing property:

Aloe Vera is known for its soothing and healing effects on burn and other wounds. Aloe Vera when applied over the wounds, it increases both the rate of wound closure and the tensile strength through proliferation of the cells.[12] This is because Aloe Vera accelerates the blood flow to the wounded areas by increasing the collagen content and extent of collagen crosslinking, thereby enhancing wound contraction and breakage of scar tissue.[13,14]. Thus Aloe Vera is the best wound dressing ever discovered.[15]

Moisturizing and anti-aging effect:

Aloe Vera possesses incredible moisturizing properties. It produces collagen and elastin fibres, making the skin more elastic and less wrinkled, thereby reverses the degenerative skin changes. Moreover it softens the skin by its cohesive action on superficial flaking epidermal cells and also improves the ability of the skin to hydrate itself. [16, 17]

Anti inflammatory property:

The anti inflammatory action of Aloe Vera not only relieves from pain and discomfort, but also accelerates the healing process. It also inhibits the cyclooxygenase pathway, thus reducing the production of prostaglandins, thereby reducing the inflammation.[16,18].

Antibacterial/ Antifungal/ Anti viral actions:

The antibacterial action of Aloe Vera improves the wound healing process by its anti inflammatory action.[19] Streptoccocus pyogenes and Streptoccocus faecalis are the two microbes that are inhibited by the action of Aloe Vera.[20,21] Whereas it shows bactericidal activity against Pseudomonas aeruginosa. [22,23] Leaf pulp and liquid fraction obtained from Aloe Vera acts against plant pathogenic fungi[24]. It’s preparation also inhibits Candida albicans.[21]Lectin containing fraction of Aloe gel directly hinders the growth of Cytomegalovirus, by impeding the protein synthesis.[25] The anthraquinone derivatives show virucidal effects on enveloped virus.[26,27] Aloe emodin inactivates most of the viruses, including Varicella zoster, influenza, pseudorabies and herpes simplex virus.[26,28]

Antiseptic effect

Aloe Vera contains 6 antiseptic agents: Lupeol, salicylic acid, urea nitrogen, cinnamonic acid, phenols and sulphur. They all have inhibitory action on fungi, bacteria and viruses.[16]

ALOE VERA IN DENTISTRY:

Aloe Vera in Periodontics

With the increasing incidence of periodontal diseases and development of antiobiotic resistance, there is a global need for alternative treatment modalities that is safe, effective and economical. Aloe Vera is a medicinal plant which has greater medicinal value and vast properties for curing and preventing oral diseases. Karim B et al carried out a study to assess the effect of Aloe vera mouthwash on the dental plaque and gingivitis and compare it with the bench mark control chlorhexidine and placebo. The results showed that Aloe vera mouthrinse is equally effective in reducing periodontal diseases as Chlorexidine. The results conclude that Aloe vera may prove to be an effective mouthwash owing to its ability in reducing periodontal indices with lesser side effects when compared to chlorhexidine.[29]. Dental caries is caused by acidogenic bacterial species, mainly S.mutans, Lactobacillus and Actinomyces. Periodontal disease is mostly associated with anaerobic gram negative rods like A. actinomycetemcomitans, P. gingivalis, Tannerellaforsythus, Bacteroides, Prevotella and Fusobacterium species. B. fragilis was used as an example of an opportunistic periodontopathogen in the study carried out by M.Fani et al, as many reports have documented the isolation of B. fragilis from dental plaque or periodontal pockets of patients with periodontitis. [30-32]. They found that Aloe vera gel exerted strong bactericidal activity against both cariogenic and periodontopathic bacteria, producing growth inhibition zones ranging in width from 32 to 54 mm.[33]Vidya D et al found that aloe vera gel provided greater improvement in clinical factors and in inhibiting the growth of pathogenic oral bacteria when delivered subgingivally compared to aloe vera irrigation and scaling and root planning alone.[34]

Anthraquinones

Inorganic

Compounds

Saccarides

Enzymes

Vitamins

Amino

Acids

Miscellaneous

Aloin

Barbaloin

Isobarbaloin

Anthranol

Aloetic acid

Ester of Cinnamic acid

Aloe-emodin

Emodin

Chrysophanic acid

Resistannol

Calcium

Sodium

Chloride

Manganese

Zinc

Chromium

Potassium sorbate

Copper

Magnesium

Iron

Cellulose

Glucose

Mannose

L-rhamnose

Aldopentose

Cyclooxygenase

Oxidase

Amylase

Catalase

Lipase

Alkaline phosphatase

Carboxypeptidase

Choline

Folic acid

Lysine

Valine

Leucine

Isoleucine

Methionine

Histidine

Arginine

Glycine

Proline

Alanine

Tyrosine

Cholesterol

Steroids

Triglycerides

Lignins

Uric acid

Gibberellin

Lectin like substance

Salicylic acid

Arachidonic acid

Aloe Vera in Endodontics:

Aloe vera has antimicrobial effect against resistant microorganisms found in pulp space i.e. Candida albicans and Enterococcus faecalis. Water, chloroform and alcohol extracts of aloe vera derived from pulp are found to have Antibacterial efficacyand can be used as an intracanalmedicament. Can be used in root canals as sedative dressing and as file lubricant.The nerve ends in a root canal are very sensitive. Aloe Vera greatly helps to lessen its sensitivity. This gel can be placed inside the pulp chambers while broaching to make aloe work in the pulp canals. Aloe can also be used as can allubricant. During closed dressings cotton pellet with CMCP drops could be added with a drop of aloe vera gel and then sealed with temporary restorations. [35] Aloe vera gel is also effective in decontaminating gutta purcha cones used in endodontics. Some gp points were placed in thioglycolate broth and incubated for 24 hours and some new gp points were taken alongside and decontaminated for 1 minute in 90% aloe vera gel, then the cones were cleaned with sterile gauze and incubated in thioglycolate broth for 24 hours.Both the tubes were closelyclosely monitored for turbidity. Gp cones which were not decontaminated and directly placed in broth developed turbidity, whereas cones that were decontaminated with aloe vera placed in the broth remain clear even after 24 hours. Hence indicating absence of microbial growth.[36]

Aloe Vera in Oral Submucous fibrosis:

A study conducted by Sudarshan et al, to compare the efficacy of A. vera with antioxidants in the treatment for OSMF it was found that A. vera recepient's responded better in all the parameters assessed and responded in all the clinic-histopathological stages, particularly in those with mild-stage clinically and early-stage histopathologically. Overall assessment of the parameters indicated that the A. vera group showed a better treatment response compared to the antioxidants group. It reduced the burning sensation and improved mouth opening ability thereby enhancing the patients' compliance. Aloe vera proves to be a relatively safe, can be applied topically, easily available, economical, noninvasive, and efficacious in the treatment for OSMF [37].

Aloe Vera in Oral Lichen Planus:

Choonhakarn et al. conducted a randomised controlled trial study to check the efficacy of A. vera gel in the treatment of oral lichen planus (OLP). He concluded that A. vera gel is significantly more effective than placebo in inducing clinical and symptomatological improvement of OLP. Hence, A. vera gel can be considered a safe alternative treatment for patients with OLP.[38]

Aloe vera in Recurrent Aphthous stomatitis:

Babaee et al. carried out a double-blind clinical trial to evaluate the topically administered A. vera gel on oral minor aphthous. The study proved that 2% oral gel of aloe vera is not only effective in decreasing the patient's pain score and wound size, but also decreased the aphthous wound healing period.[39]

Aloe Vera in Alveolar osteitis:

Sali Cept Patch is a freeze dried pledget, which contains Acemannan hydrogel. Acemannan is the name given to the large molecular-weight sugars called mucopolysaccharides that are found in Aloe Vera. They assert that this is the “active” ingredient interacts with the body's immune system, enhancing rather than overriding this system. It stimulates the macrophages, one of the principal immune response steering mechanisms of the body. After extraction, gauze saturated with Aloe vera when placed in socket and asked by the patient to bite on it, has shown improved healing and formation of blood clot.[40]

Aloe Vera as tooth paste:

George et al. conducted an in vitro comparative study on the antimicrobial activity of aloe vera tooth gel and two commercially popular tooth pastes and concluded that A. vera tooth gel was effective than two commercially popular toothpastes in controlling all the organisms Streptococcus mutans, Candida albicans, Lactobacillus acidophilus, Streptococcus mitis, Enterococcus faecalis, Prevotella intermedia, and Peptostreptococcusanaerobius. Also, the A. vera gel showed superior antibacterial effect against Streptococcus mitis despite the absence of additional fluoride.[41,42]

CONCLUSION:

Aloe vera is known for its healing ability since ancient times, but still its use in dentistry is limited. Further research is to be conducted to authenticate its use in treatment of oral lesions. In conclusion, A. vera has a promising future in dentistry, but further studies with larger sample size are needed to popularise its widespread use.

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