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  Table of Contents  
Year : 2020  |  Volume : 41  |  Issue : 3  |  Page : 148-158  

Azadirachta indica A. juss, Morinda citrifolia L. and Triphala as herbal endodontic irrigants: A scoping review

1 Department of Pedodontic, Dr HSJIDS, Panjab University, Chandigarh, India
2 Department of Conservative Dentistry, Dr HSJIDS, Panjab University, Chandigarh, India
3 Department of Periodontics, Sudha Rustagi Dental College, Faridabad, Haryana, India

Date of Submission26-Apr-2020
Date of Decision19-May-2020
Date of Acceptance19-Jul-2021
Date of Web Publication24-Feb-2022

Correspondence Address:
Archna Agnihotri
Department of Pedodontics, Dr Harvansh Singh Judge Institute of Dental Sciences, Sector-25, Chandigarh - 160 025
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ayu.AYU_102_20

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Background: The success of the root canal treatment depends on the complete elimination of the microflora, biofilms and smear layer from the pulp space. A wide variety of chemical endodontic irrigants are available to achieve disinfection and thorough debridement besides mechanical means. However, detrimental properties such as allergic potential, cytotoxicity, antimicrobial resistance and safety concerns have intrigued researchers over the years to look for safer options. Aim: The review is aimed at providing comprehensive information of the studies evaluating the efficacy of Azadirachta indica A. juss (A. indica), Morinda citrifolia L. (M. citrifolia) and Triphala (fruits of Emblica officinalis Gaertn., Terminalia chebula (Gaertn.) Roxb. and Terminalia belerica Retz.) as herbal endodontic irrigants. Materials and methods: The literature review was conducted using indexed databases (PubMed, Google Scholar, Cochrane) electronically for publications in peer-reviewed journals for relevant articles evaluating the efficacy of A. indica, Triphala, M. citrifolia as endodontic irrigant from the year 1985-March 2020. Results: A total of 58 studies were identified for full text reviewing after duplicate removal and screening title and abstracts. A total of 32 studies were included and processed for data extractions. Conclusion: Various in-vitro/in-vivo studies utilizing these herbal irrigants have documented promising results and hold the potential to replace chemical endodontic irrigants in routine practice but more preclinical and clinical trials are needed to substantiate these results before they can conclusively be recommended as intracanal irrigating solutions.

Keywords: Azadirachta indica, endodontic irrigants, Herbal, Morinda citrifolia, Triphala

How to cite this article:
Agnihotri A, Jhamb S, Shrama U, Rohtagi S. Azadirachta indica A. juss, Morinda citrifolia L. and Triphala as herbal endodontic irrigants: A scoping review. AYU 2020;41:148-58

How to cite this URL:
Agnihotri A, Jhamb S, Shrama U, Rohtagi S. Azadirachta indica A. juss, Morinda citrifolia L. and Triphala as herbal endodontic irrigants: A scoping review. AYU [serial online] 2020 [cited 2023 Jun 3];41:148-58. Available from: https://www.ayujournal.org/text.asp?2020/41/3/148/338265

   Introduction Top

In recent years, dentistry has evolved from being sacrificial to a saviour. The proponents of the dental profession have emphasized on saving a tooth diagnosed with dental caries than to resort to extraction. Root canal therapy has been the ultimate game-changer. Microorganisms have been recognized since long as the primary etiologic factors in the development of pulp and periapical lesions.[1],[2],[3] Elimination of microorganisms from the root canal system is a challenging task. The process of endodontic therapy involves important steps of biomechanical preparation along with effective cleaning of the root canal space to free it from bacteria and debris to allow hermetic sealing of the root canal. Various in-vitro and clinical evidence have shown that mechanical instrumentation alone is inadequate for complete elimination of bacteria from the root canal as it cannot reach every portion of the root canal system due to its complex anatomy, therefore, the use of irrigation forms an important step in this protocol[4],[5] Irrigants can augment mechanical debridement by flushing out debris, dissolving tissue and disinfecting the root canal system thus further reducing the bacterial count, bio-films and lubricating the root canal.[6] The ideal irrigant should be bactericidal, can dissolve necrotic tissue, remove the smear layer besides lubricating the canal and not irritate to healthy tissues.[7]

Studies have shown that the use of normal saline along with mechanical preparation of the root canal space does not provide predictable disinfection.[8],[9] The most commonly used irrigants in dentistry are sodium hypochlorite (NaOCl), chlorhexidine (CHX), ethylenediaminetetracetic acid (EDTA), citric acid, maleic acid, etc. However, they have been found to be responsible for altering the root canal microbiota, causing allergic reactions, decrease in dentinal microhardness, dentinal erosions, and biocompatibility issues.[10],[11],[12] These drawbacks coupled with resistant strains have prompted researchers to look for herbal alternatives.

The ancient folk medicines have focused on the use of herbs in both eastern and western traditional medicine. Recently, dental treatment has seen a growing trend to seek natural remedies and this approach is termed phyto-therapeutics, phyto-dentistry, or ethno-pharmacology. Indian tradition has a rich heritage of medicinal plants and herbs which have been used since time immemorial. Herbal alternatives are easily available, cost-effective, have increased shelf-life, low toxicity, and exhibit lack of microbial resistance.[13] These medicinal plants and herbs are rich in phytochemicals and are known for their analgesic, anti-inflammatory, antioxidant, anxiolytic, sedative, and antibiotic properties and have been widely used as endodontic irrigants. Herbal irrigants have been found to be bio-friendly with negligible side effects and have shown promising results in the removal of the smear layer which acts as a deterrent in successful root canal therapy.[14],[15] This paper aimed at summarizing the existing knowledge and providing a literature review of studies evaluating the efficacy of three herbs; Azadirachta indica A. juss, Morinda Citrifolia, and Triphala as herbal irrigating solutions.

   Materials and methods Top

The literature review was started with a defined background to review the studies involving interventions using A. indica A. juss, M. citrifolia, and Triphala as herbal endodontic irrigants. The indexed databases PubMed, Google Scholar, and Cochrane were electronically searched for articles published in English in peer-reviewed scientific journals from the year 1985-March 2020.

Inclusion criteria

In-vitro, ex-vivo and in-vivo comparative studies evaluating antibacterial activity of A. indica A. juss, M. citrifolia L., Triphala (Emblica officinalis Gaertn., Terminalia chebula (Gaertn.) Roxb. and Terminalia belerica Retz.) as herbal root canal irrigants and chemical endodontic irrigants such as CHX and NaOCl.

The studies were selected using the above-described protocol, titles, and abstracts. Reference lists of relevant studies were hand-searched to identify studies that might have been missed in the previous step. After screening title and abstract and duplicate removal a total of 58 articles were selected for full-text screening. Full-texts of pertinent studies were read independently of which 26 were excluded because they did not correspond with the inclusion criteria. Some articles were categorized as review articles [search strategy [Flowchart 1]].

   Results Top

Study selection

After the screening of title and abstracts and duplicate removal, a total of 58 studies were identified for full-text reviewing and assessed for eligibility. Twenty-six studies did not meet the inclusion criteria and were excluded after full-text reviewing. Thirty-two studies (13 in-vitro and 15 ex-vivo and 4 in-vivo studies) were identified for inclusion in the review.

The collected information was tabulated based on:

  1. In-vitro studies, ex-vivo studies, in-vivo studies on A. indica A. juss
  2. Studies evaluating Triphala and M. citrifolia as endodontic irrigant
  3. Studies evaluating the effect of herbal irrigants on smear layer
  4. Studies evaluating the effect of herbal irrigants on biofilms.

The studies on the comparative evaluation of methanolic and ethanolic extracts of A. indica A. juss (Neem), NaOCl and CHX as root canal irrigants were tabulated [Table 1] The in-vitro studies[16],[17],[18],[19],[20],[21],[22],[23],[24],[25] compared the antimicrobial activity of ethanolic and methanolic extracts of A. indica A. juss (Neem) to varying concentrations of NaOCl (2%, 2.5%, 3%, 5%) and CHX (0.25%, 0.5%, 2%) against Enterococcus faecalis (E. faecalis) and Candida albicans (C. albicans). In all of these studies, Neem performed equally well as NaOCl without showing any toxicity as compared to NaOCl when used at lower concentrations. One study by Jose et al.[24] however differed and concluded that 2.5% NaOCl was more effective against C. albicans as compared to ethanolic extract of Neem (25 μg/ml), but the toxicity of NaOCl was found to be higher. [Table 2]a and [Table 2]b summarizes the ex-vivo and in-vivo studies evaluating A. indica A. juss as an endodontic irrigant.
Table 1: In vitro studies on irrigant Azadirachta indica

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Table 2:

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Majority of ex-vivo studies evaluating the antimicrobial efficacy of A. indica A. juss in different solvents (ethanolic extract and 10% dimethyl sulfoxide [DMSO]) showed significant antimicrobial effect against E. faecalis and C. albicans besides being biocompatible to oral and periapical tissues.[26],[28] Although a single study by Sundaram et al.[27] marked 5.25% NaOCl significantly more effective than ethanolic extract of A. indica against E. faecalis. Three in-vivo studies[29],[30],[31] investigating the antimicrobial efficacy of ethanolic extract and commercial preparations of A. indica A. juss (GMP Krishna, India) against endodontic aerobic and anaerobic bacteria concluded that A. indica had significant antimicrobial efficacy against endodontic microflora and was equally efficacious or better than 2.5%, 3% NaOCl and 2% CHX. Furthermore, the combination of NaOCl and ethanolic A. indica leaf extract was found to be anti-microbially synergistic.

[Table 3] summarizes the in-vitro, ex-vivo and in-vivo studies evaluating the comparative efficacy of M. citrifolia and Triphala with NaOCl, CHX and A. indica A. juss. In the majority of these studies, Triphala and M. citrifolia had shown significant antibacterial effects against E. faecalis and C. albicans. Various studies showed M. citrifolia juice (MCJ) to have antimicrobial efficacy equivalent to that of 1% NaOCl and also Triphala in DMSO comparable to that of 2.5% and 5% NaOCl.[32],[33],[34],[35],[36] Although in studies by Chaitanya et al.[37] 3% NaOCl scored better than 6% MCJ and Saxena et al.[38] mean zone of inhibition was found to be higher for 2.5% NaOCl than the ethanolic extract of Triphala.
Table 3: Triphala and Morinda citrifolia

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The study by Thomas et al.[39] compared effectiveness of Diode laser in primary teeth as compared to 3% NaOCl and Triphala in 10% DMSO; in this randomized controlled trial, laser was found to be the most effective followed by Triphala which showed better antibacterial efficacy than NaOCl.

[Table 4] summarizes the efficacy of herbal irrigants in removing the smear layer. Sebatni and Kumar[40] in their study is proved that the aqueous extract of A. indica A. juss was an effective irrigating solution for the removal of the smear layer. Sowjanyaa et al.[42] concluded that Triphala in DMSO (1:1) could be used as an adjunct to EDTA as final rinse for better removal of the smear layer. Susan et al.[41] observed that combination of aqueous extract of Triphala and 5% NaOCl with ultrasonic activation and 10% Triphala in 10% DMSO were as effective as 17% EDTA and 5% NaOCl when used in combination as irrigating solutions for the removal of the smear layer. Murray et al.[43] found that when used in combination with 17% EDTA 6% MCJ was as effective as 6% NaOCl and more effective than 2% CHX in the removal of E. faecalis smear layer.
Table 4: Herbal irrigants and smear layer

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[Table 5] summarizes the studies on the use of herbal irrigants and their effect on biofilms. Tyagi et al.[44] investigated the antimicrobial efficacy of MCJ, ethanolic extracts of A. indica A. juss and propolis as compared to 5% NaOCl and found propolis to be equally effective as NaOCl against C. albicans biofilm followed by A. indica A. juss and MCJ. Garg et al.[45] in an ex-vivo study evaluating Triphala in 10% DMSO, 6% MCJ and A. indica A. juss (aqueous extract) found Triphala to be as efficacious as 5.25% NaOCl followed by A. indica and MCJ against E. faecalis biofilm. Rosaline et al.[46] found that ethanolic extract of A. indica A. juss achieved maximum reduction in adherence of E. faecalis to dentin (9.30%) followed by 5.25% NaOCl (12.50%) and least by MCJ (44.2%) and saline (86.7%). VinothKumar et al.[47] found ethanolic extract of A. indica (1:1) to provide promising results against both E. faecalis and C. albicans biofilms when compared to 5.25% NaOCl.
Table 5: Studies on herbal irrigants and biofilms

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   Discussion Top

The major objective of root canal treatment is to disinfect the entire root canal system. Cleaning, shaping, and use of antimicrobial medicaments are effective in reducing the bacterial load to some extent, but some bacteria do remain behind and multiply causing reinfection. Taking the ineffectiveness, potential side-effects and safety concerns of synthetic drugs into consideration, herbal alternatives for endodontic usage might prove to be advantageous. Over the past decade, interest in drugs derived from medicinal plants has markedly increased. This review aimed at compiling the studies evaluating the efficacy of irrigants utilizing herbs in cleaning root canal of its debris in the form of bacterial biofilm and smear layer.

A. indica A. juss (Neem) has been described for its value in traditional Indian medicinal texts.[48] Neem tree is also named as “village dispensary” as every part including the seeds, leaves and bark has a medicinal value.[49] In majority of studies reviewed, the A. indica extract used was prepared from the leaf part of the plant utilizing various solvents including ethanol, distilled water, and methanol. Several techniques are used for making the neem leaf extract utilizing different solvents.[50] Our search screened several studies that evaluated the antimicrobial properties of neem extract as an irrigant during root canal treatment and compared it with NaOCl and CHX irrigants. E. faecalis was chosen as one of the test microorganisms in most of these experiments due to its persistence in endodontically treated teeth with apical periodontics, its resistance to NaOCl and its rapid growth along the entire wall of the dentinal tubules.[51],[52],[53] In majority of in vitro studies, A. indica A. juss demonstrated significant efficacy against E. faecalis and C. albicans and proved to be as efficacious as NaOCl at various concentrations (2.5%, 3%, 5%).[26],[27],[28],[29],[30],[31]

Ex-vivo studies also showed biocompatibility with oral tissues and significant antimicrobial efficacy against E. faecalis and C. albicans equivalent to that of NaOCl. In comparative clinical studies evaluating of A. indica A. juss demonstrable reduction of aerobic and anaerobic flora was seen equivalent to that of CHX and NaOCl.

Dutta and Kundabala et al.[29] investigated the synergistic action between the herbal and chemical irrigants, which potezntiated their individual anti-microbial efficacy and they hypothesized that using the NaOCl and ethanolic A. indica leaf extract combination as an endodontic irrigant would prove beneficial. Sebatni and Kumar[40] found A. indica leaf extract in distilled water to have significant smear layer removal followed by NaOCl. The biocompatibility, antioxidant, antimicrobial properties, effective removal of smear layer and E. faecalis biofilm make it a potential agent for root canal irrigation as an alternative to NaOCl.[23]

Triphala is an ayurvedic polyherbal medicine containing Amalaki (E. officinalis Gaertn.), Bibhitaki (T. chebula [Gaertn.] Roxb.) and Haritaki (T. belerica Retz.). In various classic Ayurvedic medicine literature Triphala is considered as multi-therapeutic and with cure-all properties, it is even labeled as panacea historically.[54],[55]

Triphala has been used conventionally in Ayurvedic medicine as an antimicrobial agent.[56] The citric acids from the fruits aid in the removal of the smear layer and act as chelating agents. Different solvents have been used in the preparation of the Triphala extract such as distilled water, ethanol, DMSO; the latter being the most commonly used. Various in-vitro studies found Triphala (ethanolic extract) to be more effective than 0.5% and 1% NaOCl solution and also Triphala (10% DMSO) was marked equally effective as compared to 2.5% and 3% NaOCl solutions at eliminating E. faecalis.[36],[39] Satti et al.[32] demonstrated higher antimicrobial efficacy of aqueous extract Triphala as compared 3% NaOCl whereas a study by Saxena et al.[38] revealed 2.5% NaOCl to be more effective than ethanolic extract of Triphala.

Significant removal of smear layer was observed by Thomas et al. when Triphala was used in combination with 17% EDTA and 5% NaOCl or 5% NaOCl and ultrasonic activation.[39] Another study also showed effective removal of smear layer by 17% NaOCl along with Triphala. It was concluded that its use as an adjunctive herbal root canal irrigating solution might prove to be advantageous. Triphala thus represents a potential therapy to eliminate E. faecalis as more side-effects and risks being associated with NaOCl although further clinical trials have been recommended to evaluate its potential use as a root canal irrigant.

MCJ has been relatively new to endodontics and recommended as an alternative to NaOCl because of its chelating ability to remove the smear layer and antimicrobial activities, especially against anaerobic bacteria such as E. faecalis and C. albicans. Murray et al., investigated the antimicrobial effectiveness of MCJ against E. faecalis and found its MIC to be 6%.[43] Ex-vivo studies evaluating the efficacy of M. citrifolia as root canal irrigant showed that MCJ to be effective against E. faecalis biofilms and also in the removal of smear layer, especially when used in combination with EDTA but not to the same extent as NaOCl.[44],[45] Authors however have recommended the use of MCJ as an irrigant because of it is biocompatibility, antioxidant property, and safety profile as it is not likely to cause severe injuries to patients which might occur with the use of NaOCl accidents or if extruded out.

Herbal formulations are advantageous in many ways. They are safe, easily available, better shelf life, economical, and absence of microbial resistance so far. They are most effective when used with proper knowledge. Considering the low toxicity and antibacterial effectiveness, these herbs could be used as an adjunct to NaOCl thereby lowering its toxicity and also providing the added antioxidant advantage. Due to their high safety profile, these irrigants have the potential to replace chemical irrigants in patients with a history of allergic reactions to NaOCl and also in pediatric patients where open apices limit the use of chemical irrigants. Many studies have concluded that herbal extracts produce promising results when used as endodontic irrigants. Further studies like quantitative real-time-polymerase chain reaction and confocal microscopic examination of the biofilms could provide better insight into the herbal irrigants. Combination of these herbal irrigants can also be tested for their synergistic action and also the possible interactions between the ingredients. This review has revealed that there is a paucity of comparative clinical trials utilizing these herbal endodontic irrigants despite having good baseline data showing promising results from in-vitro and ex-vivo studies.

Randomized clinical controlled trials can be carried out to further substantiate the clinical efficacy of these herbal irrigants. However, this scoping review could not quantitatively assess and combine the research data and could only provide an overview of the literature pertaining to the use of A. indica, M. citrifolia and Triphala as herbal root canal irrigants.

   Conclusion Top

The article reviewed studies utilizing A. indica A. juss, Morinda Citrofolia, and Triphala as endodontic irrigants. Various in vitro studies of herbal products have yielded promising results, but more clinical trials are needed to substantiate the results from in-vitro studies and evaluate the biocompatibility before they can conclusively be recommended as intracanal irrigating solutions. Clinical studies investigating synergistic action utilizing various combinations of herbal irrigants at different concentrations and solvents are recommended to bridge the gaps in preclinical and clinical research activities and promote green dentistry in clinical practice in the true sense.

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Conflicts of interest

There are no conflicts of interest.

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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]

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