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Dentistry & Ayurveda V - An evidence based approach.

Sunita Amrutesh

ABOUT THE AUTHOR Abstract

Ayurvedic medications have stood the test of time and since time immemorial been used 1. Dr. Sunita Amrutesh, for various ailments. Recently there is renewed interest in use of various ayurvedic drugs Professor & HOD. for oral and dental health. . and natural products from time immemorial used for Dept. of Oral Medicine and their pharmacological applications viz. antiulcerogenic, wound healing, anti-inflammatory, Radiology, antimicrobial, antioxidant properties etc. This article attempts to review the recent studies KLE Society’s Institute of undertaken to use of natural products for oral diseases and also looks into the multitude Dental Sciences, Bangalore. prospects and perspectives of ayurveda in dentistry.

Keywords: Ayurveda, dentistry, natural products, complementary/integrative medicine

Corresponding Author:

Dr. Sunita Amrutesh, Professor & HOD Dept. of Oral Medicine and Radiology, Introduction KLE Society’s Institute of Dental Sciences, Ayurveda, the oldest medical science originating from Indian subcontinent, has been th No. 20, Yeshwantpur Suburb, practiced since the 12 century BC. Its objective is to accomplish physical, mental, Opp. CMTI, social and spiritual well- being by adopting preventive, health promoting and holistic Tumkur Road, Bangalore- approach towards life. Ayurveda is the science that developed as humans evolved. 560022. India Ayurvedic medications have stood the test of time and since time immemorial been used for various ailments. Indian subcontinent is the treasure house of numerous Email: plants and medicinal properties have been assigned to several thousands. Recently [email protected] there is renewed interest in use of various ayurvedic drugs for oral and dental health. . Correlation of dental diseases described in Ayurvedic text with the modern-day literature and various therapies and medicines used in Ayurveda have been extensively discussed in ”Dentistry and Ayurveda” sections I, II, III, IV 1,2,3,4 respectively. This article attempts to review the recent studies undertaken to use of natural products for oral diseases and also looks into the multitude prospects and perspectives of Ayurveda in dentistry.

Plants and natural products from time immemorial used for their pharmacological applications viz., antiulcerogenic, wound healing, anti-inflammatory, antimicrobial, antioxidant properties etc. Here is a list of few of these:

Plants with antiulcerogenic property :

Drugs which are commonly used as antiulcerogenic agent for peptic ulcer are as follows: Ocimum sanctum, Allophylus serratus, Desmodium gagenticum, Azadirachta indica, Hemidesmus indicus, Asparagus racemosus and Musa sapientum. 5

3 , 2011 © 2011 Plants with antimicrobial property Various plants and their immense potential in Aloe (Aloe barbadensis, Aloe vera), Apple (Malus management of dental health. sylvestris, Ashwagandha (Withania somniferum ) ,Bael In Ayurveda, dental health (called danta swasthya in tree (Aegle marmelos ), (Ocimum basilicum) , Sanskrit) is very individualistic and varies with each pepper ( betel), (Piper nigrum), person’s constitution (prakriti) and climatic changes Buttercup (Ranunculus bulbosus), Cashew (Anacardium resulting from solar, lunar and planetary influences pulsatilla), Castor bean (Ricinus communis ), Ceylon (kala-parinama).9 (Cinnamomum verum), Chili peppers, ( annuum,) ( Syzygium aromaticum), Kantkari (Solanum Xanthocarpum): Dhoopana with ,( Coriandrum sativum ), (Eucalyptus seeds of kantakari has been considered one of the globules) , (Allium sativum) , Gotu kola (Centella common treatment of dental caries; 4 Kantkari, asiatica), (Curcuma longa), Green tea (Camellia botanically known as Solanum Xanthocarpum , anti- sinensis), Henna (Lawsonia inermis), Licorice (Glycyrrhiza caries activity of the are attributed to the chemical glabra), Marigold (Calendula officinalis ), Olive oil (Olea constituent solanocarpine, carpesterol, solanocarpidine, europaea), Onion (Allium cepa ), Papaya (Carica papaya), potassium nitrate, fatty acid, diosgenin, sitosterol, ( piperita), Poppy (Papaver isochlorogenic acid, neochronogenic acid, chronogenic somniferum), Potato (Solanum tuberosum) are few of the acid, caffeic acid, solasodine, solasonine, solamargine, many Indian plants species which contain specific or quercetin, apigenin, histamine, acetylcholine. general antimicrobial activities. 6 Clove Oil (Syzygium aromaticum): Another very Plants with antioxidant property: common agent used to relief pain of dental caries is Spinach, pepper, black tea, broccoli, green tea, carrot, application of clove oil 4; the obtundent activity has been potato tomato ,blackberry, grape, olive, pineapple, attributed to the presence of eugenol in clove oil. strawberry, orange to name a few known to have Eugenol extracts from clove have often been used in potent antioxidant activity. 7 dentistry in conjunction with root canal therapy, temporary fillings, and general gum pain, since eugenol Plants with analgesic property: and other components of clove (including beta- Plants with claimed analgesic activity are as follows: caryophyllene) combine to make clove a mild anaesthetic Anicillo (Piper) species, Arnica (Arnica Montana), Betle as well as an anti-bacterial agent. Eugenol, the primary (Piper betl)e, Capsicum (Capsicum annuum), Chile component of clove's volatile oils, functions as an anti- (Capsicum annuum) , Clove (Eugenia caryophyllus), Coca inflammatory substance. Clove also contains a variety of (Erythroxylum coca), Feverview (Tanacetum parthenium), flavonoids, including kaempferol and rhamnetin, which (Zingiber officinale), Marijuana (Cannabis sativa), also contribute to clove's anti-inflammatory (and Menthol (Mentha piperata), Myrrh (Commiphora antioxidant) properties. myrrha) ,Peppermint (Mentha piperita), Poppy (Papaver somniferum) ,Tobacco (Nicotiana tabacum) ,Willow bark Garlic ( Allium sativum. LINN.): Garlic can be effective (Salix alba), Wintergreen (Gaultheria procumbens) 8 etc. in relieving the pain of tooth due to the allicin - a compound with a powerful antibiotic effect that is Plants with anti-inflammatory property: released when garlic is crushed. It is possible that this Underneath is a list of few drugs used for their anti- could slow down any bacteria involved; however it is inflammatory properties: unlikely that garlic alone could halt decay. Aloe (Aloe vera), Anestesia (Ottonia frutescents), Angelica (), Anisillo (Piper auritum), Eucalyptus (Eucalyptus globulus): Recent studies have Anisillo (Piper marginatum), Arnica (Arnica suggested that ayurvedic treatment can be employed supportively in the therapy of periodontal diseases and Montana) ,Calendula (Calendula officinalis), Camptotheca 10 (Camptotheca acuminate), seeds (Apium for routine prophylaxis. Nagata H and co-workers graveolens) ,Chamomile (Anthemis nobilis), Chickweed found that eucalyptus extract chewing gum had a (Stellaria media), Chicle (Manilkara sapota) ,Chilcuague significant effect on plague accumulation, gingival index, (Heliopsis longipes) ,Chilmecatl (Heliopsis longipes ), bleeding on probing, periodontal depth probing. Ethanol Chinchillia (Anicillo) (), Dandelion extracts (60% ethanol) from Eucalyptus globulus leaves (Taraxacum officinale), Garlic (Allium sativum), Ginger reportedly possess antibacterial activity against various (Zingiber officinale), Gotu kola (Centella asiatica), Hierba bacteria including oral bacteria. The extracts exhibit mora (Solanum nigrum), Jaborandi (Pilocarpus jaborandi), potent antibacterial activity against cariogenic bacteria Licorice( Glycyrrhiza glabra) ,Meadowsweet (Filipendula such as streptococcus mutans and streptococcus ulmaria), Onions (Allium cepa), Neem (Azadirachtia sobrinus. Macrocarpals which are polyphenols unique to indica), Periwinkle (lesser) (Vinca minor), Pine Bark( Pinus eucalyptus are major components of 60% ethanol palustris), Primrose oil (Oenothera biennis), Raspberry extracts of Eucalyptus globules leaf. Macrocarpals A, B, C, (Rubus idaeus), Sage (), Tea Tree D, H, I, J and eucalypton have been isolated. (Melaleuca alternifolia), Turmeric (Curcuma Macrocarpals A, B, C which are major components, longa) ,Willow bark (Salix alba) 8 etc. demonstrate relatively strong anticariogenic bacterial

4 , 2011 © 2011 activity against streptococcus mutans and streptococcus used in the treatment premalignant lesions in oral sobrinus. Additionally macrocarpals A, B, C possess cavity. antiperiodontopathic bacterial activity against several periodontopathic microorganisms,e.g. P gingivalis. Mango (Magnifera indica): Mango leaf contains Macrocarpal C occurs in the greatest abundance in ascorbic and phenolic acids which are known to posses eucalyptus extract.10 antibacterial properties. Studies have shown that mango leaves (magnifera indica) posses antibacterial properties The effectiveness of medicinal in both a against anaerobic dental microflora such as P. intermedia toothpaste and oral rinse on dental plaque, sulcus and P. gingivalis and can effectively used as adjuct for bleeding, and the pH of total saliva was investigated in a maintenance of oral hygiene. 18 single-blind study. Compared with the placebo preparations, the herbal ingredients significantly reduced Terminalia citrine: Tannin components of epicatechin both the approximal plaque index API and the SBI. The and catechin (Vaccinium vitis-idaea L.) showed strong pH of the total saliva was significantly displaced into the anti-microbial activity against bacteria and fungi. alkaline range by the application of the herbal products. 11 12,13 Methanol extracts of T. citrina fruit yielded known Various other studies by found that herbal tannins such as corilagin, punicalagin and chebulagic toothpaste and gum therapy produced statistically acid that were tested for anti-microbial action . significant differences in reducing plaque and stain thus reduces gingivitis and gingival bleeding. The efficacy of Arjuna (Terminalia arjuna): Arjunolic acid, ethyl an herbal-based mouthrinse to reduce gingival 14 gallate, flavone, ellagic acid and gallic acid are the active inflammation was found by Pistorius et al. constituents of T. arjuna and has been found to have antimicrobial effects. Such anti-microbial activity could Neem (Azadirachta indica): The isolation of bioactive potentially be used as a possible alternative for the compounds from Azadirachta indica, commonly known treatment of periodontal diseases .19 as the Neem plant, has led to an expanding number of scientific reports on its other interesting biological (Punica granatum): The pomegranate, properties and uses. Some of the observed anti-plaque Punica granatum L., an ancient, mystical, and highly activity of neem chewing sticks is attributed to the distinctive fruit, is the predominant member of two fibrous nature of these sticks resulting in mechanical species comprising the Punicaceae family. Topical plaque removal; however, neem plant also contain applications of pomegranate preparations have been chemotherapeutic antiplaque agents. The presence of found to be particularly effective for controlling oral gallotannins during the early stages of plaque formation inflammation, as well as bacterial and fungal counts in could effectively reduce the number of bacteria available periodontal disease and Candida-associated denture for binding to the tooth surface by increasing their stomatitis. Pomegranate extracts have been shown to physical removal from the oral cavity through aggregate scavenge free radicals and decrease macrophage formation. Additionally, the effective inhibition of oxidative stress and lipid peroxidation in animals and glucosyltransferase activity and the reduced bacterial increase plasma antioxidant capacity in elderly humans. adhesion to SHA, as seen with the presence of Numerous studies 20,21,22 demonstrate the antimicrobial gallotannin extracts, suggest some potential anti-plaque activity of pomegranate extracts. The growth of activity. It can be hypothesized that tannins effectively Staphylococcus aureus, Streptococcus pyogenes, bind to surface associated bacterial proteins, which Diplococcus pneumoniae, Escherichia coli, and Candida results in the formation of bacterial aggregates and loss albicans was inhibited via direct bacteriocidal or of glucosyltransferase activity. 15 fungicidal activity. The ellagitannin, punicalagin, is thought to be the fraction responsible for pomegranate’s Turmeric(Curcuma longa Linn): There are many uses of antibacterial activity.22 A randomized, double-blind study turmeric in dentistry. The benefits of turmeric include: found that the extract of Punica granatum has effective analgesic, antibacterial, anti-infi ammatory, anti-tumor, antifungal property against candidosis associated with anti-allergic, antioxidant, antiseptic, antispasmodic, denture stomatitis. 23 appetizer, astringent, cardiovascular, carminative, cholagogue, digestive, and diuretic.. The active Gotu kola (Centella asiatica): The gotu kola constituent of turmeric is known as curcumin. Turmeric (Centella asiatica) is found to be quite effective in can be used in relief from pain and bleeding of gingival treatment of mouth ulcers. Gotu kola is widely known to in gingivitis and periodontitis, as colorant in pit and heal wounds and promote connective tissue growth. fissure sealant or in dental-plaque detection system. 16 Asiaticoide and hypaphorine are the mixture of Chemopreventive activity of curcumin is observed when pentacyclic triterpene of Centella asiatica. It is found it is administered prior to, during, and after carcinogen that topical and oral applications of asiaticoside treatment as well as when it is given only during the improved wound healing in guinea pigs (1 mg/kg dose). promotion/progression phase of colon carcinogenesis.17 24 A preliminary and follow-up study by Sastravaha et al It is suggested that turmeric extracts can be extensively 25 investigated the effect of biodegradable chips impregnated with Centella asiatica and P. granatum

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6 , 2011 © 2011 pericarp on periodontal disease .All treatment sites dysmenorrhoea, ulcers, wounds and corns .The leaves of demonstrated a trend toward decreasing plaque and this species have a distinction of being used in Indian significant improvements were noted in pocket depth folk medicine for treating ulcers. A study evaluated the and attachment level at three months compared to antiulcer and antioxidant activities of 70% ethanolic placebo. axtract of leaves of Jasminum grandiflorum L. (JGLE). Antioxidant property is responsible for antiulcerogenic Honey(Madhu): Many studies have shown that honey activity of the extract. There was a significant dose- has antibacterial activity in vitro, and clinical case studies dependent decrease in the ulcerative lesion index have shown that application of honey to severely produced by all the three models in rats as compared to infected cutaneous wounds is capable of clearing the standard drug famotidine . The results suggested infection from the wound and improving healing. The that leaves of Jasminum grandiflorum possess potential mechanism of action is thought to be its chemical pH antiulcer activity, of which may be attributed to its and osmotic effects, which aid in its antibacterial actions. antioxidant mechanism of action.29 Thus may be tried in Research has also indicated that honey may possess the treatment oral ulcers. anti-inflammatory activity and stimulate immune responses. In vitro studies have shown increased release Lotus (Nelumbo nucifera): Lotus (Nelumbo nucifera) of tumour necrosis factor-alpha, interleukin-1beta and seeds contain alkaloids, saponins, phenolics and interleukin-6 with Manuka honey, and have suggested carbohydrates. Antioxidant activity of hydro alcoholic that the effect of honey on wound healing may be in extract of Nelumbo nucifera seeds was studied using in part related to the stimulation of inflammatory cytokines vitro and in vivo models. The results support significant from monocytes. These types of cell are known to have antioxidant nature of lotus sseds.30 26 an important role in wound healing. Visavadia BG et al reported two cases treated successfully with honey dressings. It can also be tried in treatment of various Euphorbia resinfera: Researchers at the National oral ulcerative conditions. Institutes of Health have enlisted one of the oldest known medicinal plants as a potent painkiller. Euphorbia (Sesamum indicum): The sesame plant resinfera, a cactus-like plant, is a member of the euphorb (Sesamum indicum) of the Pedaliaceae family has been family, of which there about 2000 species. The active considered a gift of nature to mankind for its ingredient, resiniferatoxin, was isolated in the 1970s. It is nutritional qualities and desirable health effects. Sesame a potent analogue of capsaicin, the substance that gives oil is considered to be the queen of oil seed crops chili peppers their pungency. It eliminates nerve cells because of its beneficiary effects. Oil pulling therapy can involved in chronic pain but does not damage other 31 be done using edible oils like sunflower or sesame oil. nerve cells. The study can be undertaken in Ashokan S 27 et al found that the oil pulling therapy management of various craniofacial neuralgia patients. showed a reduction in the plaque index, modified Guduchi (Tinospora cordifolia): Various studies have gingival scores, and total colony count of aerobic proven its efficacy as anti inflammatory, antioxidant, microorganisms in the plaque of adolescents with immunomodulator, among other properties. Statistically plaque-induced gingivitis. significant difference was observed in a recent study 32 with respect to improvement in salivary flow & in Grita Kumari (Aloe vera): The wonder drug in field of reduction in severity of mucositis in radiotherapy dermatology, aloe vera, has surprisingly shown an patients thus proving the role of guduchi (Tinospora interesting property of dentin formation. A study cordifolia) as a radioprotector. investigated the effect of acemannan (Aloe vera gel polysaccharide) on dentin formation. Primary human Conclusion dental pulp cells (PDPC) were treated with acemannan. Though a vast number of plants have not been studied The results revealed that acemannan significantly for their medicinal properties, these may become new increased pulp cell proliferation, BMP-2, ALPase activity, sources of medicinal activity. It is believed that the plants DSP expression, and mineralization, compared to the (traditional medicine) will be a major source of new untreated group. The acemannan-treated group also chemicals and raw materials for the pharmaceutical exhibited a complete homogeneous calcified dentin industry in near future. bridge and good pulp tissue organization; the data The materia medica of Ayurveda, and other similar suggested that acemannan promotes dentin formation repositories of knowledge from other cultures, by stimulating Primary human dental pulp cells represents a valuable resource for development of proliferation, differentiation, extracellular matrix medicinal preparations must be critically evaluated in formation, and mineralization. 28 terms of modern scientific parameters. It is important to carefully correlate the disease description in the ancient Jasmine (Jasminum grandiflorum): The leaves of literature with the modern etiology and clinical picture to Jasminum grandiflorum are used in the treatment of ensure correct correspondence. It is now well established odontalgia, fixing loose teeth, ulcerative stomatitis, that the concentration and profile of secondary leprosy, skin diseases, ottorrhoea, otalgia, stangury, metabolites in a plant depend on environmental,

7 , 2011 © 2011 nutritional, and photoperiodicity factors. Thus, the Randomized Trial. J Periodontol 2008:79(8): correct type of plant material is essential. Because 1378- 1385. traditional plant preparations have significant historical 11. B Willershausen, I Gruber, and G Hamm. The background, it may be ethical to clinically evaluate these influence of herbal ingredients on the plaque first and then collect modern toxicologic data. Important index and bleeding tendency of the gingiva. J classes of compounds essential for biologic activity must Clin Dent, January 1, 1991; 2(3): 75-8. be delineated. All of this knowledge will be essential for 12. D Estafan, J Gultz, JM Kaim, K Khaghany, and W proper standardization of a product. 33 Scherer. Clinical efficacy of an herbal Therapeutic approaches with herbal medicine are often toothpaste. J Clin Dent 1998; 9(2): 31-33. staggered due to lack of data on safety and efficacy and 13. W Scherer, J Gultz, SS Lee, and J Kaim. The meticulous clinical trial evidence. It is recommended ability of an herbal mouthrinse to reduce that more researches should be undertaken. gingival bleeding. J Clin Dent, 1998; 9(4): 97- 100. Acknowledgements: 14. Pistorius A, Willershausen B, Steinmeier EM, I wish to acknowledge my heartful thanks to, Dr BA Kreislert M. Efficacy of subgingival irrigation Venkatesh HOD of Govt. Ayurvedic Medical College, using herbal extracts on gingival inflammation. Bengaluru , Dr BV Kumaraswamy, retired Prof. in J Periodontol 2003; 74(5):616-22. Ayurveda , Kidwai Memorial institute Of Oncology, 15. Wolinsky LE, Mania S, Nachnani S, and Ling S. Bengaluru .I am indebted to Dr Sumona Pal for the The inhibiting effect of aqueous azadirachta tremendous help in preparing this article without whose indica (neem) extract upon bacterial properties help this article would not have been possible. My influencing in vitro plaque formation. J Dent sincere thanks are due to Dr Mubeen, Prof. & HOD., Res 1996; 75(2): 816-822. Dept. of OMR, GDCRI, Bengaluru, Dr G C Jagetia former 16. Chaturvedi TP. Uses of turmeric in dentistry: An Prof. & HOD. Dept. of Radiobiology, MAHE, for their update. Indian J Dent Res 2009; 20(1):107 -09. support. 17. Kawamori T, Lubet R, Steele VE, Kelloff GJ, Kaskey RB, Rao CV, Reddy BS. Dedications : Chemopreventive Effect of Curcumin, a I dedicate this work to, my parents Mr K Kadadi and late Naturally Occurring Anti-Inflammatory Agent, Mrs Shobha K Kadadi for imparting in me strong values during the Promotion/Progression Stages of and my family for their constant support. Colon Cancer. Cancer Res; 59:597-601. 18. Evaluation Of Antibacterial activity of magnifera References: indica on anaerobic dental microflora based on 1. Amruthesh S. Dentistry and Ayurveda-I. Indian J in vivo studies. Indian J Pathology Dent Res 2003;14:1-5 Microbiol2002;45(3) 307- 310. 2. Amruthesh S. Dentistry and Ayurveda-II. Indian 19. Therapeutic Potential of Plants as Anti- J Dent Res 2003; 14: 132-40. microbials for Drug Discovery. Perumalsamy R 3. Amruthesh S. Dentistry and Ayurveda-III. Indian and Gopalakrishnakone P. eCAM 2008; 1 - 12. J Dent Res 2007; 18:112-9. 20. Menezes SMS, Cordeiro LN, Viana GSB. Punica 4. Amruthesh S. Dentistry and ayurveda - IV: granatum (pomegranate) extract is active Classification and management of common oral against dental plaque. J Herb Pharmacotherapy. diseases. Indian J Dent Res 2008; 19:52-61. 2006;6:79–92. 5. Dharmani P, Palit G. Exploring Indian medicinal 21. Vasconcelos LC, Sampaio FC, Sampaio MCC, plants for antiulcer activity. Indian J Pharmacol Pereira MD, Higino JS, Peixoto MH. Minimum 2006; 38(2):95-9. inhibitory concentration of adherence of Punica 6. Cowan MM. Plant Products as Antimicrobial granatum Linn (pomegranate) gel against S. Agents. Clin Micro Rev.1999; 12: 564–582. mutans, S. mitis and C. albicans. Braz Dent J 7. Petti S, Scully C. Polyphenols, oral health and 2006;17:223 disease: A review .J Dent 2009;37:41 3 – 42 3. 22. Jurenka J. Therapeutic Applications of 8. Colvard MD, Cordell GA, Villalobos R, Sancho G Pomegranate (Punica granatum L.): A Review. , Soejarto DD, Pestle W et al.. Survey of medical Altern Med Rev. 2008; 13(2):128-144 ethnobotanicals for dental and oral medicine 23. Vasconcelos LC, Sampaio MC, Sampaio FC, conditions and pathologies. Journal of Higino JS. Use of Punica granatum as an Ethnopharmacology 2006;107: 134–142. antifungal agent against candidosis associated 9. Telles S, Naveen KV, Balkrishna A. .Indian J Dent with denture stomatitis. Mycoses. 2003; 46:192- Res, 2009; 20(2). 196 10. Nagata H, Inagaki Y, Tanaka M, Ojima M, 24. Maquart FX, Bellon G, Gillery P, Wegrowski Y, Kataoka K, Kuboniwa M et al. Effect of Borel JP. Stimulation of collagen synthesis in Eucalyptus Extract Chewing Gum on fibroblast cultures by a triterpene extracted Periodontal Health: A Double-Masked, from Centella asiatica. Connect Tissue Res 1990;24:107–20.

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