A randomized control institutional based study was conducted in the department of oral medicine and radiology, Meghana Institute of Dental Sciences, Nizambad, Telangana, India. Institutional Ethical Committee approval was taken before commencing the study. Informed consent was obtained from each individual who participated in the study. There were 24 males and 16 females (total 40 patients) with mean ages of 41.9 and 45.1 years of age respectively participated in the study with common tooth that was extracted being the first and second molars of mandible and maxilla respectively. The sample size was determined on the basis of key article [16]. A simple randomization method (The most common and basic method of simple randomization is flipping a coin [17]) was utilized to allocate the patients to Group A (20 patients were prescribed only analgesics and followed for seven consecutive days) and Group B (20 patients were treated with aloe-vera application, and followed for seven consecutive days). Participants who underwent atraumatic single tooth extractions (periodontal disease, carious teeth) were included in the study while patients having major systemic diseases, undergoing surgical extractions and who were not willing to participate during the follow up were excluded from the study group.

The two groups of the patients were called for follow-up after treatment on the third day and the following seventh day to check the response of analgesics and Aloe vera on the extraction site. Data obtained was recorded on a proforma specially designed for the purpose.

Procedure: Almost 500 mg capsule of Aloe vera powder was mixed with 2 ml of saline and then it was soaked with gelatin foam placed in the socket on the first appointment (i.e., on the day of extraction). Patients were asked to come on third day and seventh day for follow up. Healing was assessed using the standardized index by Landry, Turnbull and Howley [18] [Table/Fig-1]. Pain with respect to the atraumatic extraction sockets was measured on first day i.e., after two hour of extraction followed by third day, seventh day employing numeric pain rating scale [Table/Fig-2]. To increase the efficacy of the study two observers were involved in recording.

[Table/Fig-2]:

Numeric pain rating scale.

The details and the data obtained was subjected for statistical analysis using Mann-whitney U test, Wilcoxon Signed ranks test and Spearman’s rank correlation method. SPSS software was used to analyse the data.

The results obtained showed that there was a statistically significant improvement in healing of the extraction socket and also there was significant decrease in pain intensity in the patients using Aloe vera. Healing scores when compared between Group A and Group B showed statistically significant improvement with p-value <0.05. Group B (i.e., Aloe vera) showing a 90% healing on third and seventh day where as Group A (i.e., control) showing 60% healing on third day and seventh day showed statistically significant improvement with p-value <0.001 [Table/Fig-3]. Healing scores in Group A and Group B when compared between Observer 1 and Observer 2 showed no difference and statistically non significant with p-value >0.05 [Table/Fig-4,5]. Pain rating was performed with numeric pain rating scale and comparison between Group A and Group B (pain scores are given by patients) showed statistically significant improvement in Group B (p<0.05) better when compared with group A, two hours postoperatively, third and seventh day follow ups [Table/Fig-6].

Dental procedures commonly performed include dental extractions, after extraction the only way to relieve pain and other post extraction complications by using antibiotics and analgesics. On top of that, indiscriminate and irrational use of antibiotics may lead to the development of antibiotic resistance [19]. As people are realizing that modern medicine is not the soul remedy for infections today, we are looking back to the past for the alternative methods with least possible side effects. The main advantages claimed for the therapeutic use of herbal plants like Aloe vera in various ailments are they are effective, economical, no side effects and their easy availability.

In our study, the Aloe vera group showed 70% healing on the 3rd day and 90% healing on seventh day and the patients who were under analgesics showed 60% healing on third day 76% healing on seventh day. This healing potential in the Aloe vera group can be attributed three main factors [20]: (a) Reduced pain and inflammation; (b) Stimulation of fibroblasts to functionally produce collagen and proteoglycans; (c) Increased wound tensile strength. It is thus evident that Aloe has its role in pain and inflammation, where common oral disease like periodontal diseases, a known reason for tooth extraction is also treated effectively with this miracle medication.

Aloe vera is a plant blessed with various components that are useful in wound healing and regulating pain and inflammation [20]. During the process of healing, Aloe vera stimulates fibroblasts and fibroblasts produce new collagen. However, we should note that macrophages can also stimulate fibroblasts. The effect from macropahges was indirect and the effect is direct from Aloe, thus between the margins of wound new collagen forms [Table/Fig-7]. These collagen bonds are responsible for tensile strength.

[Table/Fig-7]:

Showing that collagen forms between the margins of the wound- direct action from aloe vera.

So, if the tensile strength increases, it shows the collagen production is increased by Aloe which is further indicated in reducing the spread of infections [21] [Table/Fig-8].

[Table/Fig-8]:

Shows mechanism of aloe vera.

Research has revealed that growth factors are significant for wound healing. Aloe contains growth factors that bind to the fibroblast IGF receptor in the wound area and subsequently produce collagen and proteoglycans which result in increased tensile strength of the wound. Aloe vera is also used to hinder acute inflammation however, contrasting to steroids, it stimulates fibroblasts to enhance wound healing and prevent the spread of infection. This can be considered as no less than miracle of aloe, the mechanism of action of this miracle plant is simplified and represented as follows [22–28] [Table/Fig-8]

A study by Hemalatha R et al., who compared Aloe vera and honey on the post extraction wounds have used both drugs together implicating the importance of these herbs with no much clarity between the efficacy of Aloe vera or honey playing important role in healing [22]. In the present study, we included only Aloe vera that showed Aloe by itself has a 90% healing capacity without honey. It was also appreciated that in the present study there was significant increase in wound healing on third day compared to control group [Table/Fig-9a,b]. In the present study we included pain index, there is a significant decrease in pain after two hours on the day of extraction followed by second, third and seventh day. This was the first of its kind of observation of recording pain in the study; it is a fact that post extraction the patient complaints of pain once the effect of local anaesthesia wears off, needing a dose of analgesics, in our study it was evident that two hours postoperatively when pain was more, Aloe has an appreciated action. We also correlated the results with inter observers in order to increase the efficacy of the study which was not done in the previous studies.

[Table/Fig-9]:

a) shows healing status in Group – A (control group) on third day and seventh day; b) Healing status in Group –B (Aloe vera group) third day and seventh day.

Study by few authors showed topical application of Aloe vera may cause redness, burning, stinging sensation and taken orally can cause abdominal cramps, diarrhea [29]. But in the present study we didn’t notice any side effects. The results coincides with the findings of Tsuchiya H et al., who reported that Aloe vera promote the wound healing and suggested the mechanism as antimicrobial action, which appear to be responsible for wound contraction and increased rate of epithelialization [30]. This might be the one of the reason for better healing in periodontally involved tooth having microbial aetiology in our study. Vogler BK and Ernst E list Aloe vera have 75 active constituents including the essential amino acids; vitamins, enzymes, monosaccharides and polysaccharides; and numerous organic compounds [31]. It has been theorized that acemannan (a polysaccharide extracted from Aloe vera gel) could serve as a bioactive molecule that has the capability of bone formation as it stimulates Bone Marrow Stromal Cells (BMSCs) proliferation, differentiation into osteoblasts and thus, may be a potential biomaterial for bone regeneration [32]. Thompson JE et al., reported that topically appllied Aloe vera stimulates collagen proliferation and fibroblast activity [33].

As rightly named “the plant of immortality”, Aloe vera has vast scope in the field of dentistry with its active components and proven history of safety. The present study reveals that the Aloe vera has multiple properties with no side-effects and hence, can be definitely used in many oral diseases. There is need of further human clinical trials in future utilizing the unique properties of Aloe vera like its antioxidant and immune stimulant properties in potentially malignant disorders. Randomized blinded studies with more representative sample would be more conclusive in considering the Aloe vera as main stay treatment for healing of extraction sockets. Quality assurance and standardization of Aloe vera products plays a central role which needs to be focused.

It may be concluded from the study that aloe is a safe, natural and user friendly alternative adjunct that might be feasible to promote healing of extraction sockets. Proper diagnosis, knowledge of the herbal medicine and implementation of that knowledge in the treatment planning are important in ensuring success with this therapeutic agent. Thus, Aloe vera may find a promising role in dentistry in future.