Tinospora cordifolia and its Potential Role in the Treatment of Periodontal Diseases

Introduction

Gingivitis is defined as the inflammation of gingiva in which the junctional epithelium remains attached to the tooth at the original level.¹ Dental plaque is a prerequisite for the development of gingivitis.² In a certain percentage of cases, the reversible condition of gingivitis has been noted to progress to periodontitis. Periodontitis is a complex disease involving intricate interactions of plaque with the host immune response, resulting in imbalance in the bone and connective tissue metabolism. Loss of connective tissue attachment to the teeth is the criteria that distinguishes periodontitis from gingivitis.^2,3 Albandar and Rams in 2002 reported that over 82% of adolescents in the United States have clinically overt gingivitis. The same numbers hold good worldwide, occasionally surpassing it. As the sequel to this is periodontitis, and the endpoint of untreated periodontitis is tooth loss, plaque control should be an integral aspect of our routine.⁴

With advances, methods of plaque control have progressed beyond mere toothbrushing. Measures such as chemical plaque control, ionic and sonic brushes, interdental aids and electric brushes have become common. Mechanical plaque control, albeit being the gold standard in maintaining optimal levels of oral hygiene, largely relies on patient compliance which frequently falls short when considering a large population, thus rendering it inadequate.⁵ Even in-office prophylaxis may fail to eliminate calculus and plaque from the base of deep periodontal pockets (75% of root surfaces), due to the compromised access owing to complicated pocket morphology. The available instruments at times do not serve the purpose intended. This results in retention of virulent periodontal pathogens in situ.⁶ As a measure to compensate for the limitations of both in-office and at home measures of mechanical plaque control, several systemic and locally applied chemotherapeutic agents have been used as adjuncts.3 But the safety and efficacy of these have been frequently questioned. This is especially true in relation to the antimicrobials, the overuse of which has resulted in a global concern of drug resistant organisms and is accompanied by significant adverse effects.⁷ The search for novel alternates for adjunctive use is a growing research field.

Traditionally pathogenic bacteria are considered the primary etiology; thus, their elimination can lead to arrest of disease progression and result in reduced pocket depth. But it is now well established that periodontitis is not caused by a single organism or factor, the isolation of which is key to targeted therapy.⁸ This has proven that the indiscriminate use of systemic broad spectrum antibiotics is redundant therapeutically, but has increased antibiotic resistance. This represents a major health threat globally. In addition, systemically administered medications often possess severe adverse effects calling for revaluation of risk benefit ratio.

Local Drug Delivery systems have often captured the stage, as it is possible to forego the high dosages and undesirable effects of systemic administration. Scientific research has found local administration of drugs to substantially reduce bacterial resistance compared to the systemic route. Various antimicrobial agents have been investigated and used as local drug delivery agents in the treatment of periodontal diseases. The most used include subgingival chlorhexidine, tetracycline fibers, subgingival minocycline, subgingival doxycycline, subgingival metronidazole.⁹

The concept of plants being used as medication is not novel. Through the ages, there have been anecdotal evidence, texts and folklore which speak of the efficacy of phyto-pharmaceuticals. A number of mainstream medications in use even today such as aspirin and morphine are derived from plants.¹⁰ About 80% of the people in developing countries still use traditional medicines for their health care.¹¹ In the Indian subcontinent treatise which discusses this aspect was compiled by Sushrutha and the science itself is termed ‘Ayurveda’. But the evidence for their effectiveness has always been questioned by allopathic physicians. With newer research facilities, it has become possible to scientifically prove the claims of their efficiency. The natural products derived from medicinal plants have proven to be an abundant source of biologically active compounds, many of which have been the basis for innovations in pharmaceutical industry. This also appears as a possible answer to the rising antimicrobial resistance. Phyto-pharmaceuticals are considered an untapped reservoir with only 1% of approximately 500,000 plant species present worldwide been investigated.¹²

Certain natural products have already been proven efficacious against oral pathogens.¹³ Botanicals like cutch tree (Acacia catechu), cinnamon, garlic (Allium sativum), bee glue (Propolis), Mikania laevigata, guaco (Mikania glomerate), shield sundew (Drosera peltata), Italian strawflower (Helichrysum italicum), huanglian (Coptidis rhizome), java pepper (Piper cubeba), neem (Azadirachta indica), clove (Syzygium aromaticum) and Tea tree oil (Melaleuca alternifolia) have been used against Streptococcus mutans.¹⁴ The action of the pharmaceutical is dependent on its content, based on which the multi-faceted action of herbal medication can be explained. Botanicals containing phenolic compounds have anti-inflammatory and prostaglandin synthetase-inhibiting activity, as well as being scavengers of oxygen free radicals and, subsequently influence leukocyte activity.¹⁵ Further, an in vitro study showed that the anti-oxidative effect of essential oil mouthwash expressed as the percentage inhibition of spontaneous oxidation was greater than that of chlorhexidine.¹⁶

Tinospora cordifolia

Tinospora cordifolia (Tc) is the scientific name given to the herb known as “Guduchi”, “amruthaballi” or giloy. It is noted for its applications in the management of several medical conditions, not just limited to diabetes, rheumatoid arthritis, asthma, etc. in the traditional ayurvedic literature. Recently, the identification of active phyto-chemicals from plants and their biological functions has led to active interest in plants across the globe.¹⁷

The myriad therapeutic utility, as evidenced in ancient ayurvedic texts (Sushrutha Samhita) has led to it being known as amruthaballi in Kannada, which technically means elixir. A diverse research work done on Tc ranges from experimental to clinical studies and from phytochemistry to bioefficacy.¹⁸

Phytochemical and functional constituents¹⁹

Studies on phytochemical analysis of Tc revealed that leaf extracts of plant have several active components such as flavonoids, alkaloids, phenols, tannins, steroids, terpenoids (Yamaguchi et al., 1998), carbohydrates, amino acids, proteins and saponins (Garg and Garg, 2018) due to which it is a potential medicinal plant. The specifics are tabulated in the following section.

General therapeutics of Tinospora cordifolia

The various phytochemicals evidenced in the table have demonstrated antimicrobial,^20,21 anti-inflammatory,²² immunosuppresive,²² anti-allergic, anti-diabetic²³ and antispasmodic properties and have been known to increase antibody production in vivo in animal studies.²⁴ Thus it has been used for the therapy of jaundice, rheumatism, urinary disorders, skin diseases, diabetes, anemia, inflammation, allergic disease, anti-periodic, all of which are multifactorial conditions.

Periodontal implication of Tinospora cordifolia

The antimicrobial efficacy of Tc has been proved against several bacterial species of specific relevance to periodontology. A clinical and microbiological study reported inhibitory effect of Tc on Porphyromonas gingivalis and Prevotella intermedia. ²⁵

Multitudinous in vitro studies found that methanolic extract of Tc inhibited lipid peroxide formation and scavenged hydroxyl and superoxide radicals.²⁶ A study demonstrated the free radical scavenging activity of Tc.^27,28 This enables it to be a more feasible combination to deliver the extract. An in vitro study assessed the antimicrobial potency of ethanolic extracts of Tc compared with chlorhexidine against collective subgingival microbiota. The study concluded that despite chlorhexidine being a gold standard and showed maximum antibacterial activity against subgingival microbiota than Tc, the study highlighted the importance of use of herbal alternatives in the treatment of chronic periodontitis taking into consideration the undesirable characteristics of chlorhexidine.²⁹ 

Only one report was retrieved from the literature where Tc was evaluated for its anti-plaque property in chronic periodontitis patients.³⁰ A study on efficacy of Tc against plaque and gingivitis used Tc as a mouth rinse in adjunct to scaling and routine brushing of teeth for 21 days and showed anti-plaque, anti-gingivitis, and antimicrobial action against gram negative organisms and S. mutans. ³¹

Given the multifactorial nature of periodontitis, addressing purely the microbial component would be redundant. This could be the reason for only temporary resolution, and often recurrence of periodontitis. Plausibly the employment of drugs which manage more than one component of periodontal pathogenesis would be more efficacious in disease management.

As Tc combines antibacterial effect with additional anti-inflammatory, antioxidant and immunomodulatory properties, it may be used to treat a condition such as periodontitis in its entirety as opposed to the contrary.

Other uses of Tinospora cordifolia in dentistry

A study conducted to assess the antibacterial activity of Tc against dental pathogens concluded that the methanolic extract of Tc was most effective against Staphylocoocus aureus, Streptococcus mutans, Streptococcus salivarius, Lactobacillus acidophilus, and Streptococcus sanguinis. The culmination of all the available evidence from the study was that the antibacterial activity against test microorganisms was due to the presence of secondary metabolites in plant extracts.³²

A study on influence of Tc extracts mixed with endodontic sealers on the growth of oral pathogens in root canal used Tc and bakul and the study concluded that Tc has better antibacterial efficacy as compared to bakul, since it contains alkaloids, flavonoids, steroids, tannins, phenols, and saponins compared to bakul which contain only two components responsible for its antimicrobial efficacy.³³

Other herbs used to treat periodontitis

TC is not the first herbal medication to be used to treat periodontitis. The following table briefly discusses herbs used in periodontics.

Conclusion

Herbs are emerging as a fascinating field in periodontics. This concept prompts a new horizon on the relationship between diet and gingival health. Today’s new technological era would be the right time to change the way bacteria are treated. But despite its application in several diseases, scientifically well-designed studies with isolation of active components are relatively few. At present, effects of Tc on periodontal health and maintenance are clear and evident from a lot of in vitro and in vivo studies. With so much to offer to the scientific world of medicine, the plant Tc truly acts as an incredible source. It appears as a viable and an inexpensive option for common man and can be incorporated as a treatment modality in day-to-day life.

Conflict of interest

None