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 Table of Contents  
ORIGINAL RESEARCH
Year : 2021  |  Volume : 13  |  Issue : 6  |  Page : 571-578

10% propolis as a subgingival irrigation agent after gingival curettage: A comparative study


Department of Periodontology, Faculty of Dentistry, Universitas Gadjah Mada, Yogyakarta, Indonesia

Date of Submission23-Mar-2021
Date of Decision17-May-2021
Date of Acceptance24-Aug-2021
Date of Web Publication30-Nov-2021

Correspondence Address:
Dr. Sri Pramestri Lastianny
Department of Periodontology, Faculty of Dentistry, Universitas Gadjah Mada, Jl. Denta 1, Sekip Utara, Yogyakarta 55281.
Indonesia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JIOH.JIOH_65_21

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  Abstract 

Aim: Gingival curettage is a surgical periodontal therapy that aims at eliminating periodontal pockets. To enhance the output of this treatment, subgingival irrigation after curettage could be used as adjuvant therapy. Propolis, as a natural remedy, has antibacterial, anti-inflammatory, and antioxidant properties, which makes it a promising candidate as a subgingival irrigation agent. The purpose of the study was to compare the effect of 10% propolis and 1% tetracycline as subgingival irrigation agents after curettage on plaque index (PI), probing pocket depth (PPD), bleeding on probing (BOP), and concentration of interleukin-1β (IL-1β)Materials and Methods: This comparative analytical study was performed on a total of six participants, with each participant presenting with two sites of periodontal pockets. The periodontal pockets were assigned to two treatment groups: patients receiving 10% propolis after curettage (Group A) and patients receiving 1% tetracycline after curettage (Group B). PI, PPD, BOP, and concentration of IL-1β were recorded at baseline on day 0 before curettage and on day 21 after curettage. The measured parameters were analyzed with chi-square analysis, Mann-Whitney, and independent T-test at different intervals. Results: Statistical analysis showed that group A (curettage + subgingival irrigation with 10% propolis) had better improvement on PI and greater reduction of PPD, BOP, and concentration of IL-1β on day 21, compared with group B (curettage + subgingival irrigation with 1% tetracycline) with P value of 0.014, 0.003, 0.007, and 0.000, respectively (P < 0.05). Conclusion: 10% propolis as a subgingival irrigation agent was more effective compared with 1% tetracycline in improving clinical parameters of periodontal tissue and concentration of IL-1β on patients with chronic periodontitis.

Keywords: Curettage, Propolis, Subgingival Irrigation


How to cite this article:
Sukmawati AN, Wijayanti P, Karina VM, Lastianny SP. 10% propolis as a subgingival irrigation agent after gingival curettage: A comparative study. J Int Oral Health 2021;13:571-8

How to cite this URL:
Sukmawati AN, Wijayanti P, Karina VM, Lastianny SP. 10% propolis as a subgingival irrigation agent after gingival curettage: A comparative study. J Int Oral Health [serial online] 2021 [cited 2022 Jan 27];13:571-8. Available from: https://www.jioh.org/text.asp?2021/13/6/571/331588


  Introduction Top


Periodontitis is a chronic inflammation disease on the periodontal tissue that could cause progressive destruction of gingiva, periodontal ligament, and alveolar bone that could affect an individual’s overall health significantly.[1] Gingival curettage is a technique that aims at removing the chronically inflamed granulation tissue in the lateral wall of periodontal pockets. This treatment can be used on several conditions. It can be performed to achieve new attachment in moderately deep intrabony pockets in relatively accessible areas. It can also function as a non-definitive procedure to mitigate inflammation when open flap surgeries are not possible to perform, such as in patients with systemic or psychologic problems, or in demographic limitations where surgical armamentarium needed to perform those surgeries is scarce.[2] Aside from surgical therapies, adjuvant therapy such as subgingival irrigation could also be carried out in order to optimize the treatment results, especially on cases with pocket depths more than 4 mm.[3] There are several materials that are suitable as subgingival irrigants, such as tetracycline, which is a wide-spectrum antibiotic whose use has been proven clinically.[4] Although chlorhexidine remains the gold standard in treating periodontal disease, a current study found that the use of tetracycline as a subgingival irrigation agent showed superior results compared with chlorhexidine and povidone iodine.[5] Further, tetracycline has anti-inflammatory and anticollagenase activity that make it a suitable subgingival irrigation agent.[6] On the downside, however, the use of tetracycline has the possibility to develop bacterial resistance or an allergy reaction.[7],[8]

Propolis is a natural ingredient that has many beneficial effects on health, and a few of them are anti-inflammatory and antimicrobial properties.[9] The anti-inflammatory property of propolis is mainly attributed to its flavonoid and caffeic acid phenethyl esther (CAPE) contents.[10] An in vivo study of propolis suggested that propolis could improve the healing process of gingivitis by increasing the number of fibroblasts and also increasing the neoangiogenesis.[11] Propolis also possesses the ability to inhibit biofilm formation by the bacteria.[12]

Interleukin-1β (IL-1β) is one of the proinflammatory cytokines that plays an important role in the inflammatory process and bone resorption. The concentration of IL-1β in gingival crevicular fluid (GCF) on inflamed periodontal tissues was found to be significantly higher than those in healthy periodontal tissue, thus making it a reliable parameter to assess the progress of destruction in the periodontal tissue.[13]

A clinico-microbiological study evaluating the effect of subgingival irrigation using propolis after scaling and root planing on multiple application was conducted on a previous study.[14] To the best of our knowledge, there have been no studies conducted on evaluating the single application of propolis as a subgingival irrigation agent after curettage. The aim of this study was to compare the effect of 10% propolis and 1% tetracycline as subgingival irrigation agents after curettage on PI, PPD, BOP, and concentration of interleukin-1β.


  Materials and Methods Top


Setting and design

This comparative study was performed on a total of six patients according to inclusion criteria. Patients enrolled in this study were outpatients in the Department of Periodontology, Faculty of Dentistry Universitas Gadjah Mada, Yogyakarta, Indonesia. This study was conducted during the period of November 2020–February 2021. All patients were subjected to a rapid diagnostic test (RDT) of COVID-19 to ensure the safety of all parties involved in this study.

Sampling criteria

Participants in this study were all male, nonsmoking patients with chronic periodontitis with at least two periodontal pockets on anterior lower sites with a probing depth of 4–6 mm, aged 35–45 years old, generally healthy and had no history of systemic diseases. The state of chronic periodontitis was confirmed with radiographic imaging by identifying the presence of moderate intrabony pockets in anterior lower teeth. All patients were male to avoid hormonal changes that might occur if the study were conducted on female patients. Those who required prophylaxis antibiotics before treatment, consumed long-term medications that can affect the periodontal tissue, were allergic or sensitive to either tetracycline or propolis, and received periodontal treatments in the past six months were excluded from this study.

To determine the sample size for this study, the following formula was used.

n = (Zα/2+Zβ)2 *2*σ2 / d2

Based on a previous study[15] using a power of 90% with a mean difference of 3, and standard deviation of 1.4, sample size was determined to be six patients with 12 sites (including a drop-off sample of 20%). Six patients with two periodontal pockets each were assigned to two groups, that is, curettage + subgingival irrigation with 10% propolis (Group A) and curettage + subgingival irrigation with 1% tetracycline (Group B) [Figure 1].
Figure 1: Diagram of participants’ flowchart

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Intra-examiner calibration

A single examiner blinded to the treatment groups measured and recorded the clinical parameters. Before the study, eight sites were examined 24 h apart. Calibration was accepted when there was a difference of 1 mm with a 95% significance level between two measurements. The calibration results were then analyzed with an independent t-test (P > 0.05).

Preparation of subgingival irrigation agents

To obtain 10% propolis solution, 15 mL pure propolis (Propolis Brazilian, Minas gerais Brazil, distributed by Nusa Mega Persada) was diluted with 135 mL sterile distilled water in a conical tube. The solution was then mixed carefully by using a vortex to ensure its homogeneity [Figure 2]. The 1% tetracycline solution was obtained by dissolving three capsules of 500 mg tetracycline (Zenith Pharmaceuticals, Indonesia) into 150 mL sterile distilled water at 60°C. A magnetic stirrer was used to stir the solution homogenously. Any residual particles of tetracycline were filtered properly.[4]
Figure 2: Mixing the 10% Propolis solution using a vortex mixer

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Clinical parameters

Periodontal tissue status was evaluated by measuring PI according to Sillness and Loe,[16] PPD on four tooth surfaces, and BOP. PPD is the distance from the free gingival margin to the base of the periodontal pocket, which was measured using the UNC probe (Osung, Korea).[17] BOP was measured by gently inserting the UNC probe into the gingival sulcus, and then observing the bleeding that appeared within 10 s. The BOP score was presented in percentage between the positively bleeding sites and the total sites assessed.[16] All the clinical parameters were taken at the baseline before curettage was carried out and on 21 days after the curettage and subgingival irrigation.

Collection of gingival crevicular fluid

Samples of GCF were obtained from each group at the baseline and on the 21st day of post treatment. Each site was air-dried gently and checked for any supragingival plaque. Paper point #15 (Indodent, Indonesia) was then inserted into the gingival sulcus until a mild resistance was felt, and it was kept for approximately 30 s to allow it to absorb the GCF [Figure 3]. Any paper point with contaminated blood was discarded. Selected paper points were immediately put into Eppendorf tubes (Eppendorf, Hamburg) that had been filled with phosphate buffer saline with pH 7.4 beforehand. The GCF samples were then stored at −20°C until interleukin-1β analysis using enzyme-linked immunosorbent assay (ELISA).
Figure 3: Paper point insertion to collect GCF

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ELISA test

Interleukin-1β concentration was measured using ELISA assay kit (Bioassay Technology Laboratory, Shanghai, China) according to the manufacturer’s instruction. Briefly, 50 μL of standard solution was added to a standard well. After that, 40 μL of sample was added to sample wells followed by 10 μL anti-IL-1β antibody. Then, 50 μL of streptavidin-HRP was added to both the sample wells and standard wells. The plate was covered with a sealer and then incubated for 60 min at 37°C. After the sealer was removed, the plate was washed five times using buffer. Next, 50 μL substrate solution A was added to each well, followed by the addition of 50 μL substrate solution B. The plate was covered with a new sealer for 10 min at 37°C in the dark. Then, 50 μL stop solution was added to each well, which resulted in the blue color turning yellow. The optical density of each well was determined using a microplate reader at 450 nm within 10 min after adding the stop solution. The standard curve was generated by plotting the average optical density for each standard on the vertical axis against the concentration on the horizontal axis. The concentration of IL-1β was presented in pg/L.

Curettage and subgingival irrigation

Before curettage, scaling and root planing was carried out on all the study participants. After applying local anesthesia using pehacain, curettage using a closed technique was done in the determined sites using Gracey curettes (Osung, Korea). All the necrotic tissues were cleaned thoroughly.

After curettage, the sites were isolated using cotton rolls. In group A, 10% propolis subgingival irrigation was carried out for approximately 5 min using an irrigation needle [Figure 4]. The needle tip was positioned at least 3 mm below the gingival margin to ensure thorough irrigation.[4],[18] In group B, 1% tetracycline subgingival irrigation was done using the same condition as group A. Periodontal dressing was applied afterward.
Figure 4: Subgingival irrigation after curettage

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Patients were given analgesics to ease any discomfort that might occur, and they were instructed to have recall visits at day 7 to take the periodontal dressing off and at day 21 to take the GCF sample and for recording clinical parameters.

Statistical analysis

The statistical analysis was done using statistical package for the social sciences (SPSS) software for Windows, 21.0 Version (SPSS, Chicago, Illinois). The reduction of PPD, BOP, and concentration of IL-1β were subjected to the Shapiro-Wilk test to analyze its normality. Since its distribution was not normal, the reduction of PPD data was analyzed with the Mann-Whitney test. The reduction of both BOP and concentration of IL-1β were analyzed with an independent T-test. PI data were analyzed with the chi-square test. The level of significance (P value) was set at P < 0.05.


  Results Top


In this study, there were a total of six patients involved. The postoperative wound healing was uneventful, and no patients reported adverse effects or allergic reactions to either tetracycline or propolis.

The recorded data for PPD, BOP, and concentration of IL-1β on all groups are shown in [Table 1], [Table 2], and [Table 3], respectively. The descriptive statistics of PPD, BOP, and concentration of IL-1β for each group on baseline and day 21 is shown in [Table 4]. [Table 4] shows that there was a reduction of all parameters on day 21 in both groups. The reduction value for PPD, BOP, and concentration of IL-1β was analyzed statistically and is shown in [Table 5]. The results from [Table 5] show that there were significant differences between reduction value on curettage + 10% propolis group (Group A) and curettage+1% tetracycline group (Group B) with P < 0.05. The reduction on group A was significantly greater than group B. These results were seen in all measured parameters. The PI analysis was also performed using chi-square test, and there was significant difference on PI value between group A and group B with P value: 0.014; P < 0.05 (significant).
Table 1: Pocket Probing Depth data on all groups

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Table 2: Bleeding on Probing data on all groups

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Table 3: IL-1β concentration data on all groups

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Table 4: Mean value and standard deviation on PPD, BOP, and concentration of IL-1β in each group

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Table 5: Statistical analysis for reduction of PPD, BOP, and concentration of IL-1β

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  Discussion Top


This study investigated the effect of subgingival irrigation using 10% propolis after curettage on patients with chronic periodontitis. The evaluated parameters include clinical parameters (PI, PPD, and BOP) and immunological parameter (interleukin-1β from gingival crevicular fluid). All parameters were recorded at baseline and at day 21 after curettage.

Curettage is a periodontal surgery that aims at eliminating chronically inflamed soft tissue on periodontal pockets.[2] To optimize the results on the curettage procedure, clinicians could add adjuvant therapies, such as subgingival irrigation, using several irrigation agents.

The results on day 21 after curettage showed that there were improvements on all clinical parameters and the concentration of IL-1β in all groups. Further, there were significant differences of PPD reduction value (P < 0.05), BOP reduction value (P <0.05), and concentration of IL-1β reduction value (P < 0.05) between group A and group B. Statistical analysis on PI value showed that there were differences between both groups.

This finding suggested that there was clinical and immunological improvement in all treatment groups on day 21. The new attachment on periodontal tissue that is formed after curettage is characterized by collagen fibers that are placed parallel or perpendicular to the root surface.[19] These collagen fibers appear within 21 days after wound contraction, and they will continue to undergo the remodeling process.[2],[19]

This finding is in agreement with those of a previous study by de Andrade,[20] which found that the subgingival irrigation with 20% propolis after scaling and root planing was more effective in improving probing depth, PI, gingival index, and oral hygiene index in 45 and 90 days, as compared with subgingival irrigation using saline. Another study showed that 3% ethanol propolis extract could help in removing plaque and improving the health of periodontal tissue.[21] This finding is in agreement with the finding in this study that group A showed significantly better improvement in PI on day 21 compared with group B. Bacteria have two forms of life, the planktonic form and the organized sessile aggregate (biofilm) form.[22] Bacteria have a signaling system between cells called quorum sensing, which is used to form a biofilm layer on the biotic or abiotic surfaces. This biofilm layer consists of sessile cells embedded in polysaccharide matrix, protein, lipid, and extracellular DNA produced by bacteria. Bacteria that reside in this biofilm are more resistant toward antibiotic therapy or phagocytic mechanisms by the host.[23] Bueno-silva[12] proved that propolis could inhibit biofilm or plaque formation by the bacteria by inhibiting virulence factors such as lipase and coagulase.[22]

Propolis possesses more than 300 active compounds, which could be categorized into phenolic acids, flavonoids, terpenes, lipid-wax compounds, beeswax, and other compounds such as vitamins, proteins, amino acids, and sugar.[24] Most of the biological properties of propolis are contributed by its flavonoid and caffeic acid phenethyl ester (CAPE) content.[25] A previous study found that 10% propolis that was loaded into carbonated hydroxyapatite showed the highest antibacterial activity against Aggregatibacter actinomycetemcomitans and Porphyromonas gingivalis compared with other concentrations of propolis.[26] As an anti-inflammatory agent, propolis is capable of inhibiting synthesis of prostaglandin, enhancing phagocytic activity of cells, and improving the healing process on epithelial tissues.

BOP score on group A showed greater reduction on day 21 (18.51±2.89) compared with group B (34.25±2.12). BOP score indicates the inflammation state of the gingiva. Propolis contains elements such as iron and zinc, which are crucial for collagen synthesis. Propolis also has mucoprotective ability, which is a beneficial property for the health of periodontal tissues. A study found that the use of propolis mouthwash was capable of improving the surgical wound healing in the oral cavity.[27],[28]

Tetracycline is a wide-spectrum antibiotic whose efficacy has been proven clinically.[4] It is used widely in the treatment of periodontal tissues due to its anticollagenase activity, and its ability to maintain its concentration in GCF up to two to four times higher than in the blood level.[29],[30] Propolis, on the other hand, has an antimicrobial property, although its exact mechanism against bacteria is still widely investigated. It is suggested that some active compounds in propolis, that is flavonoid, caffeic acid, benzoic acid, and cinnamic acid, work on the bacterial membrane or cell wall, which lead to functional and structural damage of the bacteria. The anti-inflammatory activity of propolis is acquired from its ability to modulate the cytokine and inflammatory mediators, such as suppressing the production of prostaglandin, histamine, and TGF-β.[31] The anti-inflammatory activity of propolis is confirmed in this study as shown in the BOP data, suggesting that its anti-inflammatory effect is at work. In an in vitro study using the murine macrophage cell line, it was suggested that propolis has anti-inflammatory and antioxidant activity by suppressing several cytokines, one of them being interleukin-1β. Flavonoid and phenolic acid act as scavengers of free radicals and inhibit nitrous oxide and cytokine production by macrophages or neutrophils. Antioxidants work by intercepting the free radical oxidation chain by donating hydrogen from the hydroxyl phenolic group, hence forming a stable chemical structure and preventing further oxidation.[32] The results from the said study is in agreement with our finding, which is that there was significant reduction of interleukin-1β concentration in the curettage+10% propolis group (1269.26±153.71).

This study evaluated the effect of subgingival irrigation after curettage on the same individuals, thus eliminating the inflammation reaction and immunological variety that can affect the results on day 21 after curettage. However, there are still few confounding factors that might have affected the results in this study, such as the knowledge level of each patient, oral hygiene awareness, nutrition intake, and diet pattern. The results in this study could be used a reference on patients with periodontitis who substantively require open flap surgeries. However, these surgeries could not be carried out due to several considerations, and hence curettage was performed as a non-definitive therapy to mitigate the inflammation.

The treatment of chronic periodontitis might require adjuvant therapy to optimize the desired outcome. Natural biomaterials possess several advantages over synthetic products, such as low toxicity, minimum to no side effects, and not causing bacterial resistance. Propolis possesses several therapeutic properties, for example, antibacterial, anti-inflammatory, and antioxidant properties. In this study, the use of 10% propolis as a subgingival irrigant was effective in improving periodontal status and caused no adverse effects. This material can be used as a promising alternative as a subgingival irrigant in daily practice. Nevertheless, the sample size in this study was relatively small, so the acquired results in this study are still yet to be confirmed with a bigger sample size and more immunological biomarkers besides IL-1β still need to be investigated.

Conclusion

Within the limitations in this study, it is suggested that subgingival irrigation using 10% propolis after curettage is effective in improving the clinical and immunological status of patients with chronic periodontitis.

Acknowledgment

None.

Financial support and sponsorship

Rekognisi Tugas Akhir (RTA) grant, Universitas Gadjah Mada, Republic of Indonesia, under contract No. 2488/UN1.P.III/DIT-LIT/PT/2020.

Conflicts of interest

There are no conflicts of interest.

Authors’ contribution

All authors have equally contributed toward the Role (Concepts, Design, Definition of intellectual content, investigation, article writing, etc.) Concepts Design, Definition of intellectual content, Investigation, Manuscript writing.

Ethical policy and institutional review board statement

This study was reviewed and approved by the Ethics Committee of the Faculty of Dentistry Universitas Gadjah Mada No. 00531/KKEP/FKG-UGM/EC/2020 dated October 19, 2020. All the procedures have been performed as per the ethical guidelines laid down by the Declaration of Helsinki (1975), as revised in 2013.

Patient declaration of consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Data availability statement

The data set used in this study is available on request from Sri Pramestri Lastianny/[email protected]

 
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

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



 

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