The effectiveness of Ocimum sanctum extract application as an Antimicrobial in the Supportive Therapy of Periodontal Disease

Anis Irmawati¹*, Sesaria Junita Mega², Nur Imamatul Ummah²,

Visilmi Kaffah Putri Ayna², Fitriatuz Zakia³, Yassir Ahmad Azzaim³, Ala’a Saif Alqhtani⁴, Raed Labib³

¹Oral Biology Departement, Faculty of Dental Medicine, Universitas Airlangga, Surabaya.

²Proffesion Student, Faculty of Dental Medicine, Universitas Airlangga, Surabaya.

³Postgraduate Student, Faculty of Dental Medicine, Universitas Airlangga, Surabaya.

⁴Department of Oral Medicine, College of Dentistry,

Jibla University for Medical and Health Science, Ibb, Yemen.

*Corresponding Author E-mail: anis-m@fkg.unair.ac.id

ABSTRACT:

Background: Periodontal disease is a periodontal tissue disease, including gingivitis to periodontitis in the oral cavity. Gingivitis is a reversible inflammatory condition of accumulation bacteria in the oral cavity with clinical signs, redness, swelling, and bleeding. Gingivitis not treated causes periodontitis and decreases bone density. According to Kemenkes (2018) prevalence of gingivitis in Indonesia 96.58% and Riskesdas (2018), prevalence of periodontitis 67.8%. The current supportive treatment for periodontal disease is chlorhexidine mouthwash. Chlorhexidine has side effects of teeth brown staining and burning sensation in the oral cavity. Therefore, an innovative approach using herbal plants with minimal side effects for application of Ocimum sanctum extract as a supportive therapy in periodontal disease. Objective: To determine the effectiveness application of Ocimum sanctum extract as an antimicrobial supportive therapy in periodontal disease. Literature Review: Chlorhexidine mouthwash is the gold standard for periodontal disease. Chlorhexidine acts as an antiseptic that inhibits the accumulation of dental plaque and broad spectrum, because it is bacteriostatic and bactericidal. Ocimum sanctum (kemangi) is a herbal plant in Asia and has five active components, eugenol, caryophyllene, germacrene-A, clemence and caryophyllene-oxide. In periodontal tissues, these substances have an antibacterial effect. Ocimum sanctum's immunomodulatory properties boost the response of the host to infection by raising interferon, IL-4, and T-helper cell levels. The antimicrobial plays a role in the early stages and progression of many periodontal illnesses in periodontal infections such Aggregatibacter actinomycetemcomitans and Porphyromonas gingivalis. Conclusion: Application of Ocimum sanctum extract is effective as an antimicrobial supportive therapy in periodontal disease.

KEYWORDS: Antimicrobial, Chlorhexidine, Ocimum sanctum extract, Periodontal disease, Supportive therapy, Good health and Well-being.

INTRODUCTION:

The supporting tissues of the teeth are affected by periodontal disease, which is brought on by bacterial activity and is characterized by inflammation, including gingivitis and periodontitis.

Periodontitis, which is an infection of the periodontal tissue marked by the loss of connection of the periodontal ligament and alveolar bone, differs from gingivitis, which is an inflammation of the gingiva. Based on data from the Ministry of Health (Kemenkes) in 2018 the prevalence of gingivitis in Indonesia has reached 96.58%, while the prevalence of periodontitis according to Basic Health Research (Riskesdas) in 2018 reached 67.8%.¹Periodontal disease is primarily caused by an imbalance between biofilms oral and responsehost also influenced by several other predisposing factors such as systemic conditions, oral hygiene, age, gender, and smoking.²

The continuous accumulation of plaque causes inflammation around the gingiva. Bacterial activity occurs in the gingival sulcus, thus triggering cellular and molecular responses of the body in the sulcus area. Bacterial toxin products produce ongoing inflammation that affects the alveolar bone and periodontal ligament and decreases the clinical attachment of the periodontal tissue.³ The patient feels loose teeth and difficulty chewing food and pain. If this condition is left unchecked, it will cause various complications of the disease to the point of losing teeth, thereby disrupting the mastication process and reducing the quality of patient health.⁴

Treatment of periodontal disease at an early stage is carried out by administering antimicrobial drugs. Administration of antimicrobials can be used to eliminate pathogenic bacteria in the oral cavity so as to reduce inflammation. The most commonly used antimicrobial drug is 0.2%. Chlorhexidine Gluconate.⁵

Chlorhexidine Gluconate (CHX) is a type of antimicrobial with a neutral pH ranging from 5-7 which dissolves in saliva and causes changes in the permeability of the bacterial cell membrane. CHX can have a bacteriostatic impact by contributing to the mobility of Ca2+ and Mg2+ as well as the loss of K+ in the cell wall.⁶ Long-term usage of CHX can cause a number of adverse effects, such as ulceration of the oral mucosa, ulceration of the teeth, brownish coloration of the teeth and tongue’s dorsum, and dry mouth (xerostomia).^6,7

In an effort to improve antimicrobial capabilities, new therapies are being developed by utilizing herbal ingredients to minimize side effects and increase the effectiveness of the compounds contained. The herbal ingredients in question is Ocimum sanctum extracts as supportive therapy in periodontal disease. Based on some previous literature, Ocimum sanctum has been used as a formulation in the treatment of disorders of the oral cavity and throat, cardiovascular, digestive, renal and other systems.⁸In numerous pharmacological studies, Ocimum sanctum showed antibacterial, antioxidant, and anti-inflammatory properties.⁹

Ocimum sanctum has several main ingredients found in essential oils including components eugenol, caryophyllene, clemene, and germarene-A. All of these ingredients are able to increase antimicrobial ability and control pathogenic bacteria in the periodontal tissue in the formation of biofilms such as species Streptococci, Lactobacilli, Aggregatibacter actinomycetemcomitans and Porphyromonas gingivalis.¹⁰The content of Ocimum sanctum demonstrated strong broad-spectrum antimicrobial activity for the treatment of gingivitis and periodontitis. Based on the potential Ocimum sanctum, this literature review aims to explain the effectiveness application of Ocimum sanctum extract as an antimicrobial in supportive therapy in periodontal disease which can be used for operators, researchers, and other medical personnel in use herbal medicine as a supportive therapy option for managing periodontal disease.

Periodontal Disease:

Disease of the periodontal tissue is one of the diseases that is often suffered by people in Indonesia. Periodontal disease conditions ranging from gingivitis to periodontitis. According to data from the Ministry of Health (Kemenkes) in 2018 the prevalence of gingivitis in Indonesia has reached 96.58%, while the prevalence of periodontitis according to Basic Health Research (Riskesdas) in 2018 has reached 67.8%.¹

An inflammatory condition affecting the soft and hard tissues of the teeth's supporting structures is called periodontal disease.¹¹ Periodontal disease is influenced by host immune factors, environmental factors around the host, and pathogenic bacterial factors in the biofilm which are the main factors in the occurrence of periodontal disease.¹² Biological or abiotic surfaces, such as teeth, can harbor consortia of microorganisms known as biofilms.⁴¹Local factors like the presence of plaque and calculus brought on by microorganisms, particularly Tannerella forsythia, Prevotella intermedia, and Treponema denticola in destructive periodontitis with deep pockets, removable partial dentures, fixed dentures, users of braces, missing teeth, and crowded teeth.³⁹ Periodontal disease is significantly influenced by the type of bacteria that make up biofilms. In the initial phases, the bacteria Fusobacterium nucleatum causes hypoxia and angiogenesis in the periodontal tissues. Other harmful anaerobic bacteria such Porphyromonas gingivalis, Tannerella forsythia, Treponema denticola, and Prevotella intermedia can colonize the subgingiva as a result of this hypoxic situation.^13,14

Figure 1. The clinical picture of periodontal disease is characterized by redness of the gingiva and bone resorption. ¹⁵

The classification of periodontal disease refers to determination The American Academy of Periodontology 1999. Diseases and conditions of the periodontal tissues are classified into gingivitis, chronic periodontitis, aggressive periodontitis, periodontitis as a manifestation of systemic disease, necrotizing periodontal disease, abscesses in the periodontal tissues, periodontitis associated with endodontic lesions, and growth or congenital abnormalities in the periodontal tissues. The dominant bacteria in each classification are also different. The dominant bacteria in gingivitis are Streptococcus spp., Fusobacterium spp., and Prevotella spp. In chronic periodontitis and aggressive periodontitis generalized dominant bacteria Porphyromonas gingivalis, whereas in localized aggressive periodontitis the dominant bacteria Aggregatibacter actinomycetemcomitans.¹⁶ However, according to some studies, there was no significant difference between the predominant bacteria in chronic and aggressive periodontitis.¹⁷

Gingivitis:

The reversible condition of gingival inflammation, which is marked by gingiva that ranges in color from red to edematous, brought on by the buildup of biofilm, is called gingivitis.¹⁵ Since gingivitis rarely leads to spontaneous bleeding, is typically painless, and frequently manifests as clinical changes, the majority of patients are unaware of its symptoms.¹⁸In its classification, gingivitis is divided into plaque-induced gingivitis and non-plaque-induced gingivitis such as fungi, viruses, bacteria, genetics, trauma, and allergies.¹⁹

Plaque builds up as a result of poor dental hygiene, which leads to gingivitis.⁴⁵The formation of microbial plaques in those with poor oral hygiene causes the most prevalent type of gingivitis, which affects the marginal gingiva. ³⁶ Dental plaque is the most common cause of plaque-induced gingivitis. Inflammatory lesions develop in the gingiva but do not spread to the mucogingival junction as a result of the combination among biofilm of plaque with the host's immune-inflammatory reaction. in order to prevent loss of attachment.²⁰ According to Buskermolen, 2018, biofilms in gingivitis conditions can increase proteolytic activity, a characteristic sign for gingivitis biofilms that are capable of invading the oral mucosa.²¹

Figure 2. Plaque induced gingivitis¹⁶

The course of gingivitis begins with the presence of plaque and biofilm which accounts for most of the inflammation of the gingiva.²² Gingivitis frequently happens as a result of the buildup of dangerous bacteria inside the gingival crevice, which triggers an inflammatory reaction in the gingival tissues. ³⁸ On histopathology, there is a picture of connective tissue infiltration by the body's defense cells such as neutrophils, macrophages, plasma cells, and lymphocytes. These defense cells accumulate, and when they combine with additional cells' destructive enzymes, collagen is broken down, blood vessels are dilated, vascular permeability is enhanced, and the gingival tissue becomes hyperplastic.²²

Periodontitis:

In more severe conditions, bacterial activity will cause inflammation to deeper areas. A destructive inflammatory condition of the teeth's supporting tissues is called periodontitis. It is due to specific microorganisms that harms the alveolar bone and periodontal ligament with clinical manifestations such as pockets, tooth mobility, loss of attachment to gingival recession.^23,24

There are different stages in the development of gingivitis into periodontitis. Initial lesion comes first. 2-4 days after the bacterial plaque has accumulated, the initial phase starts. This accumulation causes acute exudative cell migration innate immunity, one of which is neutrophils in the gingival sulcus. In early lesions, inflammation takes 4 to 10 days to develop. During this stage, T lymphocyte cells from the adaptive immune system infiltrate the tissue. The lesions will develop within 2-3 weeks and are dominated by plasma cells accompanied by damage to the gingival connective tissue matrix (Established lesion).²⁶ This damage leads to resorption of periodontal ligament and alveolar bone (Advanced lesion).²⁷ When chewing, the patient experiences tooth movement and difficulties. In addition, the patient also feels that there is food that is involved and difficult to clean on the teeth, followed by a feeling of dull pain. Food stuck is also a trigger factor for the severity of periodontal disease. If this condition is left unchecked, it will cause various complications of the disease to loss of teeth. The loss of one or several teeth actually disrupts the process of mastication, articulation, and phonation in patients. This can reduce the prognosis of treatment and the patient's long-term quality of health and life.⁴

A damaging condition that affects the structures that support teeth is called periodontitis. ⁴²According to AAP 1999, Periodontitis is classified into aggressive periodontitis and chronic periodontitis.¹⁶ Judging from age, most aggressive periodontitis is experienced by patients at a young age. However, it is possible that adult patients also experience aggressive periodontitis. In one study, it was found that patients who had previously had treatment at the dentist were less likely to experience aggressive periodontitis. Results bleeding on probing demonstrated more severe inflammation and more rapid progression in aggressive periodontitis.¹⁷ Alveolar bone resorption is 3-4 times more severe in aggressive periodontitis than in chronic periodontitis.²⁸

People those with chronic periodontitis typically have very complex and thick deposits of polymicrobial communities on impacted root surfaces, while those with aggressive periodontitis typically have thin deposits of dental plaque with little to no calculus.⁴⁰The periodontopathogenic bacteria that has recently been discussed are Tannerella forsythia, Aggregatibacter actinomycetemcomitans, Treponema denticola, P. intermedia, P. gingivalis, Campylobacter rectus and spirochetes. In previous studies, it was found that the deeper the pocket, the more the concentration of bacteria P.intermedia and P.gingivalis. this is because the deeper the pocket, the more debris that accumulates at the bottom of the pocket and the oxygen pressure and the amount of oxygen are getting smaller.²⁸ However, in other studies, there was little distinction between patients with chronic and aggressive periodontitis in terms of the concentration of the bacteria T. forsythia, P. gingivalis, P. intermedia, T. denticola, and A. Actinomycetemcomitans.¹⁷

Periodontal Disease Therapy:

Periodontal disease maintenance therapy consists of several phases including: non surgical phase, surgical phase, maintenance, and restorative phase. In the early and maintenance stages, topical and systemic administration of drugs such as anti-inflammatory and antimicrobial agents is often used. The dosage forms used are also very diverse as the mechanism of drug delivery develops (drug delivery system) better. Some preparations that are often found are mouthwashes, gels, and pastes.²⁶

Antiseptic administration aims to clean foreign bodies in the oral cavity so that they do not trigger inflammation. The antiseptic used is 0.2% chlorhexidine gluconate (CHX), which is effective against both gram-positive and gram-negative bacteria. When compared to other agents, it has consistently been the preferred option and is regarded as the gold standard.³⁷ CHX is a broad spectrum cationic antiseptic bis-biguanide with good anti-plaque and antimicrobial properties. CHX also has a neutral pH ranging from 5-7 which dissolves in the saliva of the oral cavity. Continuous use of CHX can result in several side effects, including dry mouth or xerostomia, brownish coloration of the teeth and tongue’s dorsum, hypogeusia or taste disturbance to oral ulceration.²⁹

CHX is widely used in mouthwash dosage forms. Antimicrobial ability has shown good effectiveness as a gold standard for the treatment of periodontal disease. CHX acts by preventing pellicle formation and is involved in the destabilization of the bacterial membrane, thereby preventing the absorption of the bacterial cell wall. Study in-vitro showed that, CHX has antibacterial properties which can cause changes in the permeability of bacterial cell membranes. A bacteriostatic effect of CHX can be caused by the displacement of Ca2+ and Mg2+ and the loss of K+ from the cell wall.⁶ Bacteria are killed by chlorhexidine by rupturing the cell membrane.⁴⁴CHX has side effects such as brownish coloration of the teeth and tongue’s dorsum, ulceration of the oral mucosa, presence of dry mouth conditions (xerostomia), and taste disturbances (hypogeusia).³⁰According to the other report, CHX usually causes oral side effects include brown darkening of teeth, desquamative gingivitis, dysgeusia, oral mucosa erosion, and unilateral and bilateral parotid edema, which is a very uncommon occurrence.⁴³

In addition, the use of systemic antibiotics is considered in some severe cases to prevent secondary infection. Antibiotics doxycycline, amoxicillin, to clavulanic acid are antibiotics used for the treatment of periodontal disease that play a specific role against obligate anaerobic bacteria. However, long-term use of systemic antibiotics needs to be considered because they have side effects on vital organs such as the kidneys and liver.⁵

Ocimum sanctum:

Figure 4. Ocimum sanctum (Linn ³²

Ocimum sanctum Linn. (as known as Ocimum tenuiflorum, Tulsi) of the genus Ocimum and Labiatae family very important for its therapeutic potency. Ocimum sanctum (Linn.) or Tulsi has become a pillar of the holistic health system Ayurveda of India. Ocimum sanctum recognized by the ancient Rishis and has been in use for thousands of years Ayurveda because of its various healing properties²⁹. Ocimum sanctum also known globally for more than 2000 years as one of the most versatile medicinal plants and has a broad spectrum of biological activity. Porphyromonas gingivalis and Aggregatibacter actinomycetemcomitans are microorganisms that have been tested with antimicrobial properties of Ocimum sanctum.²⁷

The "Queen of Herbs" is Ocimum sanctum. Ancient literature describes it as a medicinal herb that has been used in a variety of formulations to cure ailments affecting the mouth, throat, lungs, heart, blood, liver, kidneys, and other organ systems. In numerous pharmacological trials, Ocimum sanctum has demonstrated antibacterial, antioxidant, and anti-inflammatory properties.⁹

Holy Ocimum sanctum is advised for long-term usage because it has a high level of safety, very low toxicity, and no information on drug interactions with people at this time. Ocimum sanctum abundantly available, easy to obtain, and economical. Therefore, numerous limitations to the use of dental treatments, such as cost, availability, affordability, and popularity, can be addressed by using herbs like Ocimum sanctum in the management of oral disease.²⁷

Ocimum sanctum (Linn.) has a very complex biological composition with a large number of nutrients and physiologically active substances. Leaf Holy Ocimum sanctum (Linn.), particularly in the form of its essential oils, has antimicrobial qualities. Eugenol, caryophyllene, b-elements, germacrene-A, and a few phenolic compounds are the primary ingredients in the essential oil of Ocimum sanctum (Linn) leaves. The content with the highest percentage is eugenol (78.3%) which has antimicrobial, antioxidant and anti-inflammatory properties.³² Content from Ocimum sanctum also known to contain many biologically active compounds such as uronic acid as an anti-inflammatory, rosmarinic acid as an anti-oxidant.²⁷

DISCUSSION:

Periodontal bacteria, which are involved in the development of biofilm plaques, play a role in the pathophysiology of periodontal disease. The primary bacteria involved in the pathogenesis of periodontal disease include Porphyromonas gingivalis, Aggregatibacter actinomycetemcomitans, Treponema denticola, Prevotella intermedia, and other bacterial species. Inflammation of the periodontal tissues, which leads to gradual deterioration of the periodontal tissues, characterizes the creation of biofilm plaques.³ Dysbiotic conditions in the oral microbiome as a response to inflammation in the gingiva cause gingivitis and induce the body's defense system.host to prevent deeper biofilm formation. Biofilm spread followed by other triggering factors leads to more severe gingival inflammation and leads to clinical attachment loss, alveolar bone resorption and pocket formation. This condition is the main feature of periodontitis.²⁴

The process of pathogenesis of periodontal disease is influenced by various factors, including local factors in the form of biofilm formation, general factors including age and systemic disease, as well as the influence of economic factors.³³ Biofilm formation is influenced by host defense mechanisms and conditions oral hygiene sufferer. If these two things are not balanced, it will trigger the disease's progression in periodontal tissue. There are four steps that make up the periodontal disease progression mechanism, starting with the accumulation of plaque in the periodontal tissue (initial lesion), presence of inflammation and triggers cellular and molecular activities of the body (early lesion), Lymphocyte cell infiltration accompanied by damage to the connective tissue matrix (establish lesion), and the final phase is marked by the presence of damage that continues in the occurrence of alveolar bone resorption and periodontal ligament (advanced lesion).²⁷

The periodontal disease treatment program is modified based on patient's condition and any complications. Chlorhexidine gluconate can be administered in the form of mouthwash formulations throughout the non-surgical phase of therapy and to maintain the health of the periodontal tissues. However, usage chlorhexidine gluconate which are not according to indications for use will cause side effects in the form of presence brown staining of teeth and tongue’s dorsum, alteration of taste, oral ulceration and dry mouth conditions or xerostomia.^7,30

Periodontal tissue disease therapy continues to experience development, especially in the use of herbal medicines (herbal medicine). Holy Ocimum sanctum is a herbal plant that can be found in Indonesia which contains many compounds and nutrients that are biologically active. Contains active compounds and nutrients Ocimum sanctum contained in essential oils, can be used as an antibacterial in opposition to periodontal pathogens such, Streptococcus mutans, Aggregatibacter actinomycetemcomitans, and Porphyromonas gingivalis. Some of the ingredients that are often found in essential oils include, eugenol, caryophyllene, b-elements, germarene-A, and some phenolic components. Ocimum sanctum also contains many biologically active compounds in the form of phytochemicals such as ursonic acid, rosmarinic acid and oleanolic acid.²⁷ Among some of the contents of Ocimum sanctum above, eugenol is the highest content which can cause disruption of bacterial cell membranes by inhibiting activity of ATPase so that the Na+ and K+ pumps in the bacterial cell membrane become inhibited and bacterial cell death occurs. In addition to acting as efflux pump blocker by lowering several virulence factors at sub-inhibitor concentrations. Decreased virulence factors impact on the inability of bacteria in the efflux mechanism to eliminate an antibacterial compound from the cytoplasm. This contributes to the effectiveness of a treatment.¹⁰

Utilization of content Ocimum sanctum can be taken through the leaf extract Ocimum sanctum using a simple method. 250grams of leaves separated from the stem and sterilized with sterile distilled water. After that, it was dried for 7 days in the sun. The dried leaves are passed through a grinder until a homogeneous powder is formed. The finely milled powder was macerated with 70% ethanol for 3 days to obtain the filtrate. After obtaining the maximum amount of filtrate, the filtrate is evaporated using an evaporator to separate the extract and solvent so that a concentrated and thick basil leaf extract is obtained. Extract Holy basilIt can be applied in the form of a paste, gel or mouthwash.³⁴

Based on the articles obtained, it was found that Ocimum sanctum can be used as an alternative material that is antimicrobial, especially against bacteria Aggregatibacter actinomycetemcomitans, Intermediate prevotella, and Porphyromonas gingivalis. During the 21-day trial, Ocimum sanctum extract decreased plaque development. Ocimum sanctum's antibacterial ingredient may be the cause of this effect. Eugenol, ursolic acid, carvacrol, linalool, limatrol, caryophyllene, estragol, saponin, flavonoid, triterpenoid, and tannins are only a few of the ingredients found in Ocimum sanctum. These components combine to produce high-molecular-weight complexes with saliva-soluble proteins that can speed up bacterial lysis on salivary and dental surfaces and obstruct bacterial adhesion to the tooth surface.³⁵

Phenolic content of the extract Ocimum sanctum also showed the presence of immunomodulatory reactions both cellular and molecular immune responses in the host's body. Ocimum sanctum capable of triggering production interferon, interleukin-4, and and T Helper which may enhance the host's defense against infection. Ocimum sanctum extract is able to reduce silver particles into more complex forms (silver nanoparticles) against gram-positive and negative bacteria.³⁴ In addition, there are several phenolic components in the extract that can act as antimicrobials by damaging the bacterial cell wall membrane so that it can cause the bacteria to lyse.²⁷

Study in vitro done to see the comparison of the amount index plaque group-treated gingiva. Ocimum sanctum and groups chlorhexidine observed for up to 30 days. There was a significant difference in the treatment group with mouthwash Ocimum sanctum which shows a decrease index plaque tall one. Besides that, Ocimum sanctum can result in a significant reduction in pocket depth and good anti-inflammatory properties.⁸

It has antibacterial qualities according to previous studies. In order to combat periodontal germs like Aggregatibacter Actinomycetemcomitans, Intermediate Prevotella, and Porphyromonas gingivalis. Saint Basil is typically used with doxycycline. Aggregatibacter Actinomycetemcomitans was better inhibited by Ocimum sanctum at a concentration of 5–10%. When used against Porphyromonas gingivalis and Prevotella intermedia, holy basil displayed a reduced zone of inhibition.³⁴ In bacterial culture research it was found that, Ocimum sanctum showed the largest inhibition zone around 22mm which was directly observed at different concentrations.²⁷ Therefore, Ocimum sanctum is useful as an adjuvant in the treatment of traditional periodontal disease and is utilized as a supportive medication.

CONCLUSION:

The application of Holy Ocimum sanctum extract effective as an antimicrobial in supportive therapy in periodontal disease.

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