|Year : 2014 | Volume
| Issue : 1 | Page : 33-38
Clinical and radiographic evaluation of zinc oxide with aloe vera as an obturating material in pulpectomy: An in vivo study
Abhishek Khairwa1, Manohar Bhat1, Rajesh Sharma1, V Satish1, Prabhadevi Maganur1, Anil Kumar Goyal2
1 Department of Pedodontics with Preventive Dentistry, Jaipur Dental College and Hospital, Dhand, TehsiAmer, Jaipur-Delhi NH-11C, India
2 Department of Pedodontics with Preventive Dentistry, Government Dental College and Hospital, Shastri Nagar, Jaipur, Rajasthan, India
|Date of Web Publication||15-Feb-2014|
Department of Pedodontics with Preventive Dentistry, Jaipur Dental College and Hospital, Dhand, TehsiAmer, Jaipur-Delhi NH-11C, Jaipur - 303 101, Rajasthan
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Pulp therapy for pulpally involved primary teeth continues to be a challenge to clinicians. One of the major areas of continued research is in the area of finding obturating materials to suit the specific properties of these teeth. Zinc oxide eugenol is used frequently in pulpectomy for the obturation of the primary teeth. Aims: To evaluate clinically and radiographically a mixture of zinc oxide eugenol and aloe vera as an obturating material. Materials and Methods: A total of 50 children, aged between 4 and 9 years, who were screened for unilateral or bilateral carious deciduous molars were studied. Out of these, 15 children were randomly selected for endodontic treatment. Obturation was done with a mixture of zinc oxide powder and aloe vera gel. Clinical and radiographic evaluation was done after 7 days, 1 month, 3 months, 6 months, and 9 months. The data were statistically analyzed. Results and Conclusion: Endodontic treatment using a mixture of zinc oxide powder and aloe vera gel in primary teeth has shown good clinical and radiographic success. A detailed observational study with longer follow-up will highlight the benefits of aloe vera in primary teeth as an obturating medium.
Keywords: Aloe vera gel, obturating materials, primary teeth, pulpectomy, zinc oxide eugenol
|How to cite this article:|
Khairwa A, Bhat M, Sharma R, Satish V, Maganur P, Goyal AK. Clinical and radiographic evaluation of zinc oxide with aloe vera as an obturating material in pulpectomy: An in vivo study. J Indian Soc Pedod Prev Dent 2014;32:33-8
|How to cite this URL:|
Khairwa A, Bhat M, Sharma R, Satish V, Maganur P, Goyal AK. Clinical and radiographic evaluation of zinc oxide with aloe vera as an obturating material in pulpectomy: An in vivo study. J Indian Soc Pedod Prev Dent [serial online] 2014 [cited 2019 Dec 9];32:33-8. Available from: http://www.jisppd.com/text.asp?2014/32/1/33/127051
| Introduction|| |
The best space maintainer in both primary and mixed dentition is the primary tooth itself. This is not only because of the clinical crown but also due to the presence of the roots and periodontium that guide the eruption of the succedaneous permanent tooth. Primary teeth also stimulate development of maxilla and help in masticatory process. Thus, preserving the integrity of primary dentition is important for the adequate development of permanent dentition. ,
These teeth should be preserved until they are ready to be replaced. Thus, primary tooth pulpectomy should be done as a routine procedure after proper examination and diagnosis confirms its necessity. In view of this, endodontic treatment is considered the last option for keeping a primary tooth that has irreversibly affected pulp tissue, due to caries or traumatic lesions, in a child.
The ultimate goal of endodontic obturation has remained the same for the past 50 years, i.e. to create a fluid-tight seal along the length of the root canal system, from the coronal opening to the apical termination.
Presently, the commonly used materials for primary root canal fillings are zinc oxide eugenol[ ZnOE], iodoform-based pastes, and calcium hydroxide. 
Aloe vera is an herbal and naturally found material, and its anti-inflammatory, and anti-bacterial and pain-relieving properties have made possible its wide usage in dentistry for various therapeutic purposes. 
The present study was conducted to test the clinical and radiographic efficacy of zinc oxide powder and aloe vera gel mixture as obturating agents in primary teeth.
Aims and objective
- Clinical evaluation of the mixture of zinc oxide powder and aloe vera gel as an obturating material in pulpectomy at different time intervals
- Radiographic evaluation of the mixture of zinc oxide powder and aloe vera gel as an obturating material in pulpectomy at different time intervals
| Materials and Methods|| |
A total of 50 children, aged between 4 and 9 years, who were having unilateral or bilateral carious deciduous molar in mandibular arch were selected from the outpatient clinic of the Department of Pedodontics and Preventive Dentistry, Jaipur Dental College and Hospital, Jaipur. Out of the screened 50 children, 15 were selected. They were in good general health, having no history of systemic illness or hospitalization. Consent was obtained from the ethical committee constituted by the college and from the parents or guardian of the child prior to start of the study.
Once the patients were selected, the teeth which had the following clinical and radiographic criteria were selected. 
The clinical and radiographic criteria are presented in [Table 1].
Preparation of zinc oxide and aloe vera gel mixture
Zinc oxide powder and aloe vera gel were mixed on a mixing pad with the help of a stainless steel spatula, and the mixing ratio of zinc oxide and aloe vera was 1:2. [Figure 1]a and b
|Figure 1: (a) Zinc oxide powder and aloe vera gel; (b) Mixture ready for placement|
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Local anesthesia for the selected tooth to be treated was achieved by inferior alveolar nerve block using 2% lignocaine hydrochloride with adrenaline 1:80,000, followed by isolation using rubber dam, and a straight line access cavity was achieved depending on the extent of the lesion [Figure 2]. Coronal pulp was removed with a spoon excavator. This was followed by chemo-mechanical preparation that was carried out using K files and appropriate irrigating solutions to remove the necrotic pulp tissue. All the canals were dried using paper points. Then, the canals were obturated with the mixture of zinc oxide powder and aloe vera gel by using pluggers and reamers [Figure 3]. Radiographic confirmation was done [Figure 4]. Then access cavity was restored with composite [Figure 5] followed by stainless steel crowns.
Patients were recalled after 7 days [Figure 6], 1 month [Figure 7], 3 months [Figure 8], 6 months [Figure 9], and 9 months [Figure 10], and evaluated according to the clinical and radiographic criteria.
The cases treated were considered as successful when they had the following conditions: absence of pain, absence of tenderness to percussion, and absence or decrease of mobility.
| Results|| |
Pulpectomy, using a mixture of zinc oxide powder and aloe vera as a root canal obturation material, was carried out in a total of 15 primary molars. In all the cases, obturation was at proper length. No overfilling or underfilling was seen.
[Table 2] and Graph 1 show the clinical signs and symptoms reported from baseline to 9-month follow-up period.
|Table 2: Distribution of various clinical signs and symptoms reported at baseline and after treatment (in percentage)|
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Incidence of pain was seen in all the patients preoperatively. Pain was observed in two patients after a period of 9 months. This reduction was highly significant. Thus, at the end of 9 months, there was reduction of pain in 86.67% of cases.
Tenderness to percussion was noted in all the patients preoperatively. Tenderness to percussion was observed in one patient (6.66%) after 9 months of treatment. At the end of 9 months, there was reduction of tenderness to percussion in 93.34% of cases and was highly significant.
In our study, mobility and sinus or fistula was present in all the patients preoperatively. No mobility and sinus formation was observed in any of the patients at any time interval. The results were highly significant.
[Table 3] and Graph 2 show that radiolucency was present in all the 15 cases before the start of the study. Radiographic examination was carried out at 7 days, 1 month, 3 months, 6 months, and 9 months interval. Development of radiolucency was observed in four cases (26.66%) after 9 months. It was observed that 11 cases (73.34%) demonstrated arrest or decrease of radiolucency. This was highly significant.
|Table 3: Distribution of presence and decrease of radiolucency in furcation at various intervals|
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| Discussion|| |
With predictable management and the cooperation of children in clinics for dental treatment and better understanding of the morphology of the root canals of primary teeth, more and more clinicians recommend and perform pulpectomy procedures in primary teeth. The primary goal of root canal treatment is to eliminate infection and retain the tooth in a functional state until it is normally exfoliated.
Pulp management of the infected primary teeth involves not only thorough debridement of the root canal system but also obturation by using a material which is biocompatible and would resorb at the same rate as the roots of the involved tooth, without endangering the succedaneous permanent tooth and its eruption. Till date, numerous materials (ZnOE calcium hydroxide, calcium hydroxide with iodoform paste, KRI paste, Maisto's paste, Walkhoff's paste, etc.) have been tested for their efficiency as a root canal filling material, but none of these have been shown to possess the requisite properties of an ideal root canal filling material for primary teeth, especially with regard to the major desirable property of having a rate of resorption matching that of the physiologic root resorption of the primary teeth. Zinc oxide eugenol paste is the most frequently used root canal filling material for primary teeth because of the beneficial effects of eugenol.
Bonastre (1837) discovered zinc oxide eugenol, and it was subsequently used in dentistry by Chisholm (1876). Zinc oxide eugenol paste was the first root canal filling material to be recommended for primary teeth, as described by Sweet in 1930. Hashieh  studied the beneficial effects of eugenol. The amount of eugenol released in the periapical zone immediately after placement is 10-4, and it falls to 10-6 after 24 h and reaches zero after 1 month. In these concentrations, eugenol is said to have anti-inflammatory and analgesic properties that are very useful after a pulpectomy procedure. However, it has certain disadvantages like slow resorption, irritation to the periapical tissues, necrosis of bone and cementum, and alters the path of eruption of succedaneous tooth. Success rates were reported after obturating with zinc oxide eugenol cement by various authors as follows: 82.3% by Barr et al., 82.5% by Gould,  and 86.1% by Coll et al.
To overcome the drawbacks of ZnOE (slow rate of resorption) and calcium hydroxide (faster rate of resorption from within the canals), Chawla et al.  used a mixture of calcium hydroxide and zinc oxide as a root canal filling material, but this material also got depleted from the canals earlier as compared to the physiologic root resorption. The thirst for venturing out an ideal obturating material which meets all the requirements is still in an experimental stage.
Aloe vera is an herbal and naturally found material. Herbal compounds are being used by about 80% of the world population primarily in the developing countries for primary health care. They have stood the test of time for their safety, efficacy, cultural acceptability, and lesser side effects. The chemical constituents present in them are part of the physiological functions of living flora, and hence, they are believed to have better compatibility with the human body.
Aloe vera can be used for various therapeutic as well as preventive purposes owing to its anti-inflammatory, antibacterial, antifungal, antiviral, moisturizing, and pain-relieving properties, and is used in the treatment of minor burns, skin abrasions, and irritations, and in the treatment of psoriasis and frostbite. The antimicrobial effects of aloe vera have been attributed to the plant's natural anthraquinones: aloe emodin, aloetic acid, aloin, anthracene, anthranol, barbaloin, chrysophanic acid, ethereal oil, ester of cinnamonic acid, isobarbaloin, and resistannol.  In relatively small concentrations, together with the gel fraction, these anthraquinones exhibit analgesic, antibacterial, antifungal, and antiviral activities; in high concentrations, they can be toxic. The uses of aloe vera are also proved in dentistry in the following areas: 
- Periodontal surgery
- Application to the gum tissue traumatized or scratched by tooth brush, dental floss, toothpick injuries
- Chemical burns are relieved quickly from accidents with aspirin.
- Extraction sites respond more comfortably and dry sockets do not develop when aloe vera is applied.
- Acute mouth lesions are improved by direct application on herpetic viral lesions, aphthous ulcers, canker sores, and cracks occurring at the corners of our lips. Gum abscesses are soothed by the applications as well.
- Other oral diseases chronic in nature respond with lichen planus and benign pemphigus. Even gum problems associated with AIDS and leukemia patients are relieved. Migratory glossitis, geographic tongue, and burning mouth syndrome are improved.
- Denture patients with sore ridges and ill-fitting dentures and partials can benefit as fungal and bacterial contamination reduce the inflammatory irritations.
- Aloe vera can also be used around dental implants to control inflammation from bacterial contamination.
Because of these properties that are useful in dentistry, aloe vera gel can be also used in any obturating medium for therapeutic purposes.
To improve the properties and success rate, ZnOE has been tried with many compounds, but the addition of these compounds neither increased the success rate nor made the material more resorbable as compared to ZnOE alone. Eugenol also acts as an irritable factor in the periapical region and when it is mixed zinc oxide powder, it sets as a hard mass. Whereas zinc oxide powder, if mixed with aloe vera gel, provides the following advantages: it does not set, its ease of placement, easily retrievable nature, etc. So, in this study, we have used zinc oxide powder with aloe vera gel to check the efficacy of this combination as an obturating material for primary teeth.
| Conclusion|| |
From the results obtained, it can be observed that endodontic treatment using a mixture of zinc oxide powder and aloe vera gel in primary teeth has shown good clinical and radiographic success.
However, we advocate further clinical and histological studies with longer follow-up till the period of tooth exfoliation to ascertain the efficacy of this novel treatment modality, and the development of aloe vera based mouthwashes and tooth pastes should be advocated.
| References|| |
|1.||Brothwell DJ. Guidelines on the use of space maintainers following premature loss of primary teeth. J Can Dent Assoc 1997;63:753-66. |
|2.||da Costa CC, Almeida IC, Locks A, da Costa Filho LC. Clinical comparative study of the effects of two types of mandibular space-regaining devices. Gen Dent 2003;51:120-6. |
|3.||Camp JH. Pulp therapy for primary and young permanent teeth. Dent Clin North Am 1984;28:651-68. |
|4.||Davis RH. Aloe vera: A scientific approach. NewYork: Vantage Press; 1997. |
|5.||Nadkarni U, Damle SG. Comparative evaluation of calcium hydroxide and zinc oxide eugenol as rootn canal filling material in primary molars: A clinical and radiographic study. J Indian soc pedo prev dent 2000;1:1-10 |
|6.||Hashieh IA, Ponnmel L, Camps J. Concentration of Eugenol apically released from ZnOE based sealers. J Endocrinol 1999;22:713-5. |
|7.||Barr ES, Flaitz CM, Hicks MJ. A retrospective radiographic evaluation of primary molar pulpectomies. Pediatr Dent 1991;13:4-9. |
|8.||Gould JM. Root canal therapy for infected primary molar teeth: Preliminary report. ASDC J Dent Child 1972;39:269-73. |
|9.||Coll JA, Josell S, Casper JS. Evaluation of a one-appointment formocresol pulpectomy technique for primary molars. Pediatr. Dent 1985;7:123-9. |
|10.||Chawla HS, Mathur VP, Gauba K, Goyal A. A mixture of calcium hydroxide paste and zinc oxide as a root canal filling material for primary teeth: A preliminary study. J Indian Soc Pedod Prev Dent 2001;19:107-9. |
|11.||Aloe vera: Its potential use in wound healing and disease control in oral conditions. By Timothy E. Moore, D.D.S./M.S.,P.C. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10]
[Table 1], [Table 2], [Table 3]