Brazilian biodiversity is very rich and offers thousands of plants with therapeutic potential that over the years have shifted from popular use to clinical use, in particular phytotherapy is a treatment option that has been growing popular in culture and scientific society. Several pathologies or conditions can be treated with herbal medicines. The confirmation of phytotherapics in the treatment of various disorders becomes the target of scientific practice, certifying not only the benefits of medicinal plants, but also the precautions, contraindications and care inherent in its use. Among the main medicinal plants used both in Medicine and Dentistry in Brazil, we find the barbatimão (Stryphnodendron adstringens), a small tree easily found in the Brazilian cerrado (vegetation of the Brazilian interior). It is rich in tannins, whose pharmacological properties help healing, thanks to its anti-inflammatory, hemostatic, antiseptic and antidiarrheal actions.
Materials and Methods
Three cases are reported where dental abscesses with suppuration, with pulp and periapical involvement or with residual roots were treated with mouthwashes obtained with infusion from the decoction of the barbatimão barks. These mouthwashes were used,prior to dental procedures, namely endodontic and periodontal treatments and exodontia.
The dental abscesses showed improvements thanks to the astringent properties of barbatimão, and the other dental procedures were favored due to reduction of suppuration.
The use of barbatimão ahowed an effective action in the treatment of dental conditions, particularly in the process of tissue repair and as antibacterial and antifungal agent.
Dentistry, Ethnopharmacology, Medicinal plants, Pharmacognosy, Phytotherapy, Plant extracts.
Phytotherapy has predated the use of pharmacology for millennia. From the beginnings of mankind, there is knowledge of the use of plants for therapeutic purposes. Probably, even before the first cases were recorded, the use of medicinal plants as a therapeutic option was a common practice of primitive civilizations. Since ancient times there have been reports on the use of medicinal plants, such as poppy and mandrake, starting with Mesopotamian civilization. In the world scenario, medicinal herbs are important in several health systems of great proportions, such as traditional Chinese medicine, a millenarian art that incorporates more than 7,000 species of plants in its clinical practice (1). Each population, based on its particular mode and according to the local flora, experimented and created its recipes and its posology (2,3).
Currently, there is an increased interest in medicinal plants, due to the great demand for complementary and alternative therapies. This is mainly due to the inefficacy of some synthetic products, the high cost of medicines and the search of the population for less aggressive treatments to the human organism. Phytotherapeutic medicines are preparations of drugs (extracts, tinctures, infusions, ointments and capsules) with medicinal herbs, obtained from one or more plants and used for the treatment of various diseases. There are countless benefits from therapeutic use, such as low cost and high availability for the low-income population (4,5). Many of these drugs are indicated in dental therapy.
The knowledge about the use of medicinal plants in modern and urban society has been passed on in an empirical way from generation to generation by herbalists, popularly known in South America as raizeiros (people consecrated by popular culture for their knowledge about preparation, indication and administration of medicinal plants). However, due to the development of the pharmaceutical industry, the process of urbanization and cultural and social changes, this knowledge has been lost. It is important to retrieve this knowledge also in urban areas, both for its historical and cultural value, and for information on the appropriate use (6). Moreover, it is necessary to deepen the scientific evidence of these drugs, as well as collect adequate knowledge for the dentist to prescribe them correctly (1).
There are between 250,000 to 500,000 species of plants on planet Earth, and a small percentage is used to treat diseases. These compounds have been isolated and subjected to detailed structural analysis and their possible modes of action and elucidated target sites. Several plants used in popular medicine were studied for their antimicrobial activity as a source of new antifungal compounds with lower side effects, broader action spectrum and lower cost (7).
In this perspective, the Brazilian Ministry of Health has sought to stimulate the insertion of complementary care practices in the health system. In 2006, the National Policy on Medicinal Plants and Phytotherapics (PNPMF) and the National Policy on Integrative and Complementary Practices (PNPIC) were implemented, aiming at increasing access to medicinal plants and other complementary practices, standardizing information on scientific evidence, thus enabling health care in an effective and safe way (2,8). The dental surgeon is able to prescribe and use Integrative and Complementary Practices to oral health for the benefit of patients (8), and the inclusion of phytotherapy in dental procedures in routine clinical practice should be based on scientific evidence.
The purpose of this study was to present three cases of dental abscesses with suppuration, with pulp and periapical involvement, or in cases of residual roots, in which a mouthwash from barbatimão bark infusion was used in conjunction with dental procedures (endodontic and periodontal treatments and exodontia), which showed improvements thanks to the astringent property of the barbatimão.
Reports of cases
A female patient, Caucasian, 46 years old, attended the private clinic complaining of gingival abscess on tooth 21 and generalized and advanced periodontal disease (Figure 1, 2).
Endodontic (tooth 21) and complete periodontal treatments were indicated. However, due to the amount of suppuration observed, both fistula due to gingival abscess and generalized periodontal disease, barbatimão bark infusion mouthwash, 3 to 6 times a day, for 7 days was recommended, in order to reduce suppuration and favor the installation of anesthesia for proper treatment because of the astringent properties. The patient was instructed not to persist in the use of mouthwashes to avoid causing extrinsic pigmentation in the teeth. After the time indicated for the mouthwash, recommended treatments were performed (Figure 3, 4).
A female patient, Caucasian, 45 years old, attended the private practice complaining of alveolus-dental abscess on tooth 35 (Figure 5).
In the extraoral clinical examination, edema in the left mandibular region was observed (Figure 6).
Radiographically, radiolucent periapical image was noticed (Figure 7), motivating indication of endodontic treatment in tooth 35.
Due to the amount of suppuration observed, the use of mouthwash with infusion of barbatimão bark 3 to 6 times a day for 7 days was suggested. The patient was instructed not to persist in the use of conventional mouthwashes in order to avoid causing extrinsic pigmentation in the teeth. In addition, endodontic treatment was performed, with involution of edema and suppuration (Figure 8-10).
A male Caucasian patient, 54 years old, attended the private clinic complaining of a gingival fistula adjacent to the residual roots of teeth 35 and 36 (Figure 11).
Radiographically, radiolucent periapical images were observed (Figure 12), with indication of exodontia.
The mouthwash was used 3 to 6 times a day during the 7 days prior to the surgical procedure. The patient was instructed not to persist in the use of conventional mouthwashes in order to avoid causing extrinsic pigmentation in the teeth. After 7 days, the exodontia was performed, with the regression of edema and suppuration (Figure 13, 14).
In the post-surgical control sutures were removed (Figure 15), and tissue repair was observed (including gingival fistula).
Barbatimão (Stryphnodendron adstringens) is a native species of Brazilian cerrado. It is a small tree (8 to 20 meters), found from the Amazon Region of the State of Pará, extending through the central plateau to the southeast region (states of Minas Gerais and São Paulo) (9).
Several components are identified in the biological composition of barbatimão: ferric chloride, copper acetate, lead acetate and glacial acetic acid, which indicate the presence of phenolic derivatives, possibly derived from tannins, in bark, stems, leaves and fruits of barbatimão. Its action results from the ability of protein precipitation and complexation and its power to sequester metal ions, mainly iron, essential for the development of microorganisms, thus developing the antimicrobial action. Tannins have high antioxidant activity due to the inactivation of free radicals, also preventing the lipid peroxidation and degradation of nucleotides, accelerating the cicatrization process. In addition, it consists of alkaloids, starch, flavonoids, proanthocyanidins, resinous materials, mucilages, dyes and saponins (10-12). The predominant presence of flavones and flavonoids in leaf and bark extracts, and flavanols in the stem extract indicate antioxidant, anti-inflammatory and anticancer functions. Depsides and depsidones present antioxidant, antiviral, antitumor, analgesic and antipyretic properties. Additionally, the presence of foamy saponin is observed, suggesting association with hemolytic, antiviral, anti-inflammatory, and cardiac congestive failure reduction by inhibition of sodium cellular efflux (12). Actions in the control of parasitoses and vectors were also reported (10). Treatment of leukorrhea and gynecological infections, as well as diarrhea, by means of decoction and infusion of barbatimão stem bark was reported to have anti-inflammatory and astringent properties (13,14).
In oral health, barbatimão, as also shown in the present work, presented positive results in the treatment of acute or chronic gingivitis (15). It is postulated that, due to the astringent properties, the barbatimão can reduce purulent suppuration, helping other dental procedures, as well as favoring the setting of anesthesia, which would be hampered by the pH of the secretion. Tannins present in barbatimão are able to precipitate salivary glycoproteins, causing the loss of oral lubricating power - resulting in the sensation popularly known to Brazilians as "tying the mouth." In addition, this fact can result in two other occurrences: reduction or increase of pH, a variation that disadvantages local antimicrobial activity; and the process of precipitation and complexation of the proteins and lipoproteins present in the inflammatory and infectious process through the tannins (1).
Although the toxicity of medicinal plants is considered by a large part of the Brazilian population to be trivial, the adverse effects of these herbal medicines can be significant, becoming a serious public health problem. Pharmacological tests to evaluate the toxic action of barbatimão suggest that, according to the dose, bark extract contains substances capable of affecting the Central Nervous System, Respiratory System and Gastrointestinal Tract (6,10). Potential cytotoxic, genotoxic, teratogenic and abortive effects were reported, restricting their use by pregnant women (2,10).
Phytotherapy has been growing exponentially for a variety of reasons, such as cultural, social and economic factors, as well as offering a lower risk to health. In this perspective, the use of barbatimão by the Brazilian population proved to have an effective phytotherapic action in the treatment of dental affections, particularly in the process of tissue repair and as antibacterial and antifungal agent. However, it is important to carry out prospective studies of several orders to prove and validate its pharmacological potential.
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