|Year : 2017 | Volume
| Issue : 2 | Page : 58-63
In vivo evaluation of honey as a new medicament for vital pulp therapy in primary teeth
K Krishna Kumari1, E Sridevi2, A Jogendra Sai Sankar2, A Satya Gopal2, K Pranitha2, MG Manoj Kumar3
1 Department of Pedodontics and Preventive Dentistry, Dr. Shyamala Reddy Dental College, Bengaluru, Karnataka, India
2 Department of Pedodontics and Preventive Dentistry, Sibar Institute of Dental Sciences, Guntur, Andhra Pradesh, India
3 Department of Pedodontics and Preventive Dentistry, Pananeeya Dental College, Hyderabad, Andhra Pradesh, India
|Date of Web Publication||8-Jun-2017|
A Jogendra Sai Sankar
Department of Pedodontics and Preventive Dentistry, Sibar Institute of Dental Sciences, Guntur, Andhra Pradesh
Objectives: In spite of clinical success, the pulpotomy technique has been questioned for safety and effectiveness of currently available medicaments. In search of newer materials, there is a rapid research toward natural health remedies. Thus, an in vivo study was conducted to evaluate and compare the clinical and radiographic success of honey and formocresol (FC) as pulpotomy agents. Materials and Methods: A total of 100 mandibular primary molars were selected from 50 healthy children aged between 3 and 8 years following the inclusion and exclusion criteria for pulpotomy procedure. The teeth were divided into two equal groups; in Group A, honey was used as pulpal medicament and in Group B, FC as control. Further, all the pulpotomised teeth were restored with stainless steel crowns and postoperative evaluation was done at 1, 3, 6, 9, and 12 months interval. Results: Clinically, both the groups showed 100% success during the follow-up periods. Even though 100% radiographic success was recorded for Group A and B after 1 month interval, the values dipped to 95.6% and 95.4% at 3 months, 91.3% and 90.9% after 6 months, 91.3% and 86.3% after 9 months, and 86.9% and 77.2% after 12 months, respectively. Conclusion: Although honey showed promising results both clinically and radiographically, long-term follow-up is recommended to investigate the efficacy of honey as viable alternative to FC.
Keywords: Formocresol, honey, pulpotomy
|How to cite this article:|
Kumari K K, Sridevi E, Sai Sankar A J, Gopal A S, Pranitha K, Manoj Kumar M G. In vivo evaluation of honey as a new medicament for vital pulp therapy in primary teeth. SRM J Res Dent Sci 2017;8:58-63
|How to cite this URL:|
Kumari K K, Sridevi E, Sai Sankar A J, Gopal A S, Pranitha K, Manoj Kumar M G. In vivo evaluation of honey as a new medicament for vital pulp therapy in primary teeth. SRM J Res Dent Sci [serial online] 2017 [cited 2017 Oct 20];8:58-63. Available from: http://www.srmjrds.in/text.asp?2017/8/2/58/207657
| Introduction|| |
Conservation of primary dentition is essential for maintenance of arch length, esthetics, mastication, speech, and prevention of abnormal habits. Caries progress to involve the pulp more frequently in primary teeth, in view of the fact that enamel and dentin thickness is less. Such teeth with coronally inflamed vital pulp can be salvaged by pulpotomy, which is a vital pulp therapy technique. Wide variety of medicaments such as formocresol (FC), ferric sulfate, calcium hydroxide, collagen, pulpotec and mineral trioxide aggregate, electrocautery, and lasers were used to treat the remaining radicular pulp tissue after pulpotomy.
Over the years, FC remained the benchmark medicament for pulpotomy procedure due to its very high and consistent results that date back to more than a century. Despite FC's high success rate and its position as “gold standard” in pulpotomy, a substantial shift has occurred from the use of this medicament because of two main reasons. FC itself being a connective tissue irritant causes devitalization of radicular pulp and second concern regarding its systemic effects such as toxicity, mutagenecity, carcinogenicity, and antigenecity., The international agency for research on cancer classified formaldehyde as carcinogenic for humans in June 2004 leaving the profession to look for other alternatives to FC.
Natural products have been used for several years in folk medicine. Among the natural products, medicinal importance of honey has been well documented in the literature as it has been known to possess antimicrobial as well as wound healing property. Its healing properties can be ascribed to the fact that it offers anti-bacterial activity, maintains a moist wound environment that promotes healing, and has a high viscosity which helps provide a protective barrier to prevent infection.
Considering the beneficial effects of honey, which have been proven in many animal and human clinical studies,, this in vivo study was designed to evaluate the effectiveness of honey by considering the pulpotomised portion as an open wound.
| Materials and Methods|| |
An ethical approval was obtained from Ethics Review Committee to conduct this clinical study. After obtaining parental consent children with good systemic health, no reported history of allergy to the test medicaments and deep carious lesions on the mandibular primary molars without any advanced clinical and radiographic manifestations of pulpal pathology were included in the study. Total sample includes 100 teeth from 50 healthy children which constitute both mandibular first and second primary molars of both the sexes within the age range of 3–8 years (mean age 5.1 ± 1.2 years) attending the outpatient Department of Pediatric Dentistry were randomly selected for 3 months. The teeth were then divided into two equal groups and the coronal pulp was amputated using the conventional pulpotomy technique. In Group A, samples were treated with honey (Jivaka Ayurvedic and Allied Products Industrial Co-operative Society Ltd., Angalakuduru, Tenali, Guntur, Andhra Pradesh, India) and Group B (control) with Formocresol (Pharmadent Remedies Pvt. Ltd., Vadodara, India). The efficacy of each medicament as a therapeutic modality was assessed throughout the recall program.
Pre operative periapical radiographs were obtained from each tooth before treatment. The teeth were anesthetized with 2% lidocaine with 1:100,000 epinephrine and isolated with a rubber dam. After removing the superficial soft caries, initial occlusal access was prepared using a high-speed dental handpiece and a #330 bur under water spray. Pulp amputation was completed with a #4 slow-speed round bur and spoon excavator and hemostasis was achieved by placing sterile cotton pellet moistened with saline over the pulp stumps. In Group A, a drop of honey was dispensed using a disposable syringe and left for 5 min [Figure 1]. In Group B, a sterile cotton pellet moistened with a 1:5 dilution of FC was placed in contact with the pulp orifices for 5 min. After ascertaining the fixation of the tissue, a thick mix of zinc oxide eugenol cement was placed. In both groups, at the time of the pulpotomy visit, all teeth were restored with glass ionomer cement (Ketac Molar Easy Mix, 3M, ESPE). Final restoration with a stainless steel crown (3M) was given within 1 week following the pulpotomy procedure. Teeth in both the groups were reviewed after 6, 9, 12, 18, and 24 months interval for both clinical and radiographic success that encompassed asymptomatic tooth; absence of a sinus tract; absence of furcal radiolucencies, pathologic resorption, and/or damage to succedaneous follicle and premature tooth loss  [Figure 2] and [Figure 3].
|Figure 1: Clinical procedure of pulpotomy with honey (a) appearance of radicular pulp on amputating coronal pulp and obtaining hemostasis (b) radicular pulp being treated with honey (c) ultimate appearance of radicular pulp|
Click here to view
|Figure 2: Clinical photographs of the pulpotomised tooth using honey (Group A) and formocresol (Group B) - (a) At 6 months, (b) 9 months, (c) 12 months, (d) 18 months, and (e) 24-month follow-up|
Click here to view
|Figure 3: Radiographs (intra oral periapical radiograph) of the pulpotomised tooth in Group A and B sample – (a) at 6 months, (b) 9 months, (c) 12 months, (d) 18 months, and (e) 24-month follow-up|
Click here to view
Clinical and radiographic outcome assessment was made by two independent experienced clinicians who were blind to the treatment. As there was no statistical significant difference (P < 0.05) in scores given by both the examiners, the same values were considered and statistically analyzed using the Chi-square test.
Beyond the study period, certain teeth which have been extracted for orthodontic reasons were processed for histological evaluation. Immediately after postextraction, using a no. 330 bur in a high-speed handpiece, the stainless steel crown was removed and the teeth were fixed in 10% formalin for 48 h followed by the placement in 10% nitric acid solution till the specimens were completely decalcified. After processing, these specimens were embedded in paraffin wax and sections of 5 μm thickness were obtained using soft tissue microtome which were further stained using hematoxylin and eosin solutions. The sections were examined under microscope and digital photomicrographs were obtained under ×40 magnification.
| Results|| |
Children who were not regular for follow-up visits were dropped out from the study. Twenty subjects representing 45 teeth were available for a first (6 months) follow-up visit. Nineteen subjects representing 43 teeth were available for a second (9 months) follow-up visit. Seventeen subjects representing 40 teeth were available for a third (12 months) follow-up visit. Thirteen subjects representing 27 teeth were available for a fourth (18 months) follow-up visit. Ten subjects representing 23 teeth were available for final (24 months) follow-up visit in Group A.
Twenty-four subjects representing 46 teeth were available for a first (6 months) follow-up visit. Seventeen subjects representing 37 teeth were available for a second (9 months) follow-up visit. Fifteen subjects representing 30 teeth were available for a third (12 months) follow-up visit. Twelve subjects representing 25 teeth were available for a fourth (18 months) follow-up visit. Eight subjects representing 22 teeth were available for final (24 months) follow-up visit in Group B.
Clinical evaluation yielded 100% success rate for both the groups at all the time intervals [Table 1]. Whereas radiographic evaluation of Group A samples during 24 months evaluation period showed 3 failures. Among the three failures, two exhibited furcal radiolucency at 9 and 24 months interval. The third failure was external root resorption at 12-month evaluation period [Figure 4]. In Group B, five radiographic failures were noticed. Among them, four were furcal radiolucency at 9, 12, and 24 months interval and the fifth one was external tooth resorption at 18 months interval [Figure 5].
|Figure 4: Failure in Group A samples – (a) pre operative, intra oral periapical radiograph, (b) post operative intra oral periapical radiograph, (c) at 9 months, (d) 12 months, and (e) 24-month follow-up showing furcal radiolucency|
Click here to view
|Figure 5: Failures in Group B samples – Case I: (a and b) Pre operative and post operative intra oral periapical radiograph, (c) At-6 month follow-up, (d) 12 months, and (e) 18-month follow-up showing external root resorption and furcal radiolucency Case II: (f and g) Pre operative and post operative intra oral periapical radiograph, (h) At 9-month follow-up, (i) 12 months, and (j) 24-month follow-up showing furcal radiolucency|
Click here to view
| Discussion|| |
Pulpotomy technique has been the choice for treating vital primary and young permanent teeth with carious, mechanical, and traumatic pulp exposures. The ideal pulpotomy medicament/technique should be bioinductive or at least biocompatible, bactericidal, and harmless to the pulp and surrounding structures. Thus, there is constant seek out for such an ideal material/technique to treat the remaining radicular pulp through maintaining its vitality. In search of newer materials, there is a rapid research towards natural health remedies, considering that they may fulfill the above-mentioned criteria without causing any harm to the adjoining living tissues.
From ancient times, honey has been used by human beings as food as well as medicine for the treatment of variety of systemic diseases such as respiratory diseases including asthma, urinary, gastrointestinal, and skin diseases including ulcers, wounds, eczema, psoriasis, seborrhic dermatitis, and dandruff. Many authors reported various utilities of honey due to its identified antimicrobial action, anti-inflammatory property. Its unique ability to autolyte the debrided and deodorize wound; ability to stimulate tissue growth from the wound margins; and its ability to manage pain and minimize scarring.
In the view of above-mentioned sanctified properties of honey, this natural product was selected for the study. Dudhamal et al., 2010 reported that a chronic wound (skin) on lower limb was treated successfully with local application of honey in a 70-year-old female patient who was refractory to regular allopathic medicine. The dental pulp being a specialized loose connective tissue containing cells, fibers, ground substance, blood vessels, and nerve endings; the components found in pulp are very much similar to those found in dermal and epidermal layers of skin. Hence, in the present study, pulp stumps were considered as an open wound and honey was applied directly on it.
FC was taken as control group as it is the time tested medicament for pulpotomy. A systematic review on FC reported clinical success rate of 85%–100% and 75%–100% radiographic success. The results of this study revealed the clinical and radiographic success rates of FC as 100% and 77.2%, respectively, which were within the range of reported success rates in literature.
The clinical and radiographic evaluation of pulpotomised teeth in honey group showed a success rate of 100% and 86.9%, respectively. Even though both the groups showed 100% clinical success rate, radiographic failures were noticed in both the groups. However, higher radiographic success rate was observed in the honey group that can be attributed to the fore-mentioned sanctified properties of honey [Table 2].
|Table 2: Radiographic success/failure in Groups A and B samples during follow-up period|
Click here to view
The antibacterial property of honey was first recognized in 1892 by Van Ketel. The minimum inhibitory concentration was found to range from 1.8% to 10. 8% (v/v). According to White and Doner (1980), it was stated that the major antibacterial substance present in honey is hydrogen peroxide and also demonstrated that it is produced by the enzyme glucose oxidase of honey. Glucose oxidase, catalyses the oxidation of some of the glucose present in honey to form gluconic acid, thus resulting in low pH and thereby inhibits microbial growth. In the present study, H2O2 produced as a natural by-product from honey might be beneficial for the antimicrobial action at pulpotomised site, it is helpful in elimination of any residual infection.
The other important factor which would have been attributed to the success of honey as pulpotomy agent may be due to its property of increasing the rate of healing attributed to its acidic nature and anti-inflammatory properties. The acidity of honey helps in providing oxygen to regenerating tissue as it decreases the pH of the wound bed and thus makes more oxygen available from haemoglobin in the blood. Honey has been found to significantly stimulate the release of the cytokines tumor necrosis factor-α, interleukin (IL)-1β, and IL-6 from monocytes, known to play an important role in healing and tissue repair.
Honey can be expected to have a direct nutrient effect on regenerating tissue because it contains a wide range of amino acids, vitamins, and trace elements in addition to large quantities of readily assimilable sugars. The Vitamin C content in honey is typically more than three times higher than that in serum, which could be of particular importance because of the essential role of this vitamin in collagen synthesis.
As previous histological studies had already reported chronic inflammation, active resorption, and apposition of hard tissue following FC pulpotomies,, histological evaluation of only honey samples has been done. Decalcified sections (radicular pulp) exhibited fibrocellular connective tissue stroma adjacent to normal dentinal tubules, bundles of collagen fibers with plump fibroblasts, and areas of blood vessels [Figure 6]a. Similar observations were found in previous histological studies done on animal models., Interestingly, fibrous connective tissue stroma with bundles of collagen fibers and areas of hematoxyphilic structures (mineralized components) was observed in one of the samples [Figure 6]b.
|Figure 6: (a) Photomicrographs showing fibrocellular connective tissue stroma adjacent to normal dentinal tubules, bundles of collagen fibers with plump fibroblasts, and areas of blood vessels in honey samples. (b) Photomicrographs showing fibrous connective tissue stroma with bundles of collagen fibers and areas of hematoxyphilic structures (mineralized components)|
Click here to view
| Conclusion|| |
The 24-month follow-up showed higher radiographic success in samples treated with honey than FC even though the results were not statistically significant. Further clinical, radiological, and histological studies with large sample size and long follow-up are required to consider honey as a viable alternative to FC.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Farrokh Gisoure E. Comparison of three pulpotomy agents in primary molars: A randomised clinical trial. Iran Endod J 2011;6:11-4.
Jayam C, Mitra M, Mishra J, Bhattacharya B, Jana B. Evaluation and comparison of white mineral trioxide aggregate and formocresol medicaments in primary tooth pulpotomy: Clinical and radiographic study. J Indian Soc Pedod Prev Dent 2014;32:13-8.
] [Full text]
Ratnakumari N, Thomas B. A histopathological comparison of pulpal response to chitra-cpc and formocresol used as pulpotomy agents in primary teeth: A clinical trial. Int J Clin Pediatr Dent 2012;5:6-13.
Abdul SG, Ashfaq AK, Shoaib A, Khalil A, Maqbool AR. Healing effects of natural honey oral minor aphthous ulcers among dental patients in Quetta. Pak Oral Dent J 2012;32:412-5.
Mandal MD, Mandal S. Honey: Its medicinal property and antibacterial activity. Asian Pac J Trop Biomed 2011;1:154-60.
Green AE. Wound healing properties of honey. Br J Surg 1988;75:1278.
Namias N. Honey in the management of infections. Surg Infect (Larchmt) 2003;4:219-26.
Saltzman B, Sigal M, Clokie C, Rukavina J, Titley K, Kulkarni GV. Assessment of a novel alternative to conventional formocresol-zinc oxide eugenol pulpotomy for the treatment of pulpally involved human primary teeth: Diode laser-mineral trioxide aggregate pulpotomy. Int J Paediatr Dent 2005;15:437-47.
Haddad S, Maysara D. Effect of honey for treatment of some common oral lesions: Follow-up of 50 cases. J Dent Oral Hyg 2013;5:55-61.
Cooper RA, Molan PC, Harding KG. Antibacterial activity of honey against strains of Staphylococcus aureus
from infected wounds. J R Soc Med 1999;92:283-5.
Haynes JS, Callaghan R. Properties of honey: Its mode of action and clinical outcomes. Wounds UK 2011;7:50-7.
Dudhamal TS, Gupta SK, Bhuyan C. Role of honey (Madhu) in the management of wounds (Dushta Vrana). Int J Ayurveda Res 2010;1:271-3.
] [Full text]
Grando Mattuella L, Westphalen Bento L, de Figueiredo JA, Nör JE, de Araujo FB, Fossati AC. Vascular endothelial growth factor and its relationship with the dental pulp. J Endod 2007;33:524-30.
Fallahinejad Ghajari M, Mirkarimi M, Vatanpour M, Kharrazi Fard MJ. Comparison of pulpotomy with formocresol and MTA in primary molars: A systematic review and meta-analysis. Iran Endod J 2008;3:45-9.
Dustmann JH. Antibacterial effect of honey. Apiacta1979;14:7-11.
White JW, Doner L. Honey composition and properties. Beekeeping in the United States. Agriculture Handbook Number 335. Philadelphia: Eastern Regional Research Center;1980.
Molan PC. The antibacterial activity of honey. The nature of antibacterial activity. Bee World 1992;73:5-28.
Molan PC. The evidence and the rationale for the use of honey as a wound dressing. Wound Pract Res 2011;19:204-20.
Rölling I, Hasselgren G, Tronstad L. Morphologic and enzyme histochemical observations on the pulp of human primary molars 3 to 5 years after formocresol treatment. Oral Surg Oral Med Oral Pathol 1976;42:518-28.
Salako N, Joseph B, Ritwik P, Salonen J, John P, Junaid TA. Comparison of bioactive glass, mineral trioxide aggregate, ferric sulfate, and formocresol as pulpotomy agents in rat molar. Dent Traumatol 2003;19:314-20.
Gupta SK, Singh H, Varshney AC, Prakash P. Therapeutic efficacy of honey in infected wounds in buffaloes. Indian J Anim Sci 1992;62:521-3.
Suguna L, Chandrakasan G, Thomas Joseph K. Influence of honey on collagen metabolism during wound healing in rats. J Clin Biochem Nutr 1992;13:7-12.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
[Table 1], [Table 2]