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Can natural irrigants replace sodium hypochlorite? A systematic review

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Abstract

Context

Sodium hypochlorite, a gold standard for irrigation in endodontics, has disadvantages like toxicity and root dentin weakening. Alternatives derived from natural products are being explored.

Aims

This systematic review was done to understand the clinical benefits of natural irrigants when compared with a standard irrigant, sodium hypochlorite.

Settings and design registration

This systematic review was registered with PROSPERO (2018 CRD42018112837)

Methods and material

This review was done in conformation to the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA 2020) statement. In vivo studies using at least one natural irrigant and sodium hypochlorite (NaOCl) were included. Studies using them as medicaments were excluded. PubMed, Cochrane and SCOPUS were searched. RevMan tool for Risk of Bias 2 (RoB 2) and risk-of-bias tool to assess non-randomized studies of interventions (ROBINS-I) were used. GRADEpro was used to assess certainty of evidence.

Results

Ten articles (6 RCTs and 4 clinical studies) on approximately 442 patients were included. Seven natural irrigants were evaluated clinically. Due to the heterogeneity, meta-analysis could not be conducted. Antimicrobial efficacy was found to be similar for castor oil, neem, garlic-lemon, noni, papaine and NaOCl. Neem, papaine-chloramine, neem-NaOCl and neem-CHX were superior, while propolis, miswak and garlic were inferior to NaOCl. Post-operative pain was less for neem. There was no significant difference between papaine-chloramine, garlic extract and sodium hypochlorite in clinical/radiographic success.

Conclusions

The studied natural irrigants are not more efficacious than NaOCl. At the moment, they cannot replace NaOCl routinely and may only substitute in select cases.

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Acknowledgements

The authors thank the post-graduate students and interns who helped during the search of databases.

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Authors and Affiliations

  1. Department of Conservative Dentistry & Endodontics, Madha Dental College & Hospital, Somangalam, Kavanoor Road, Kundrathur, Chennai, Tamil Nadu, 600069, India

    Anand Venkatraman Susila, Shamini Sai & Aruna Kumari Veronica

  2. Department of Conservative Dentistry & Endodontics, Shree Bankey Bihari Dental College and Research Centre, Masuri, NH 24, Ghaziabad, Uttar Pradesh, India

    Nikita Sharma

  3. Department of Public Health Dentistry, Saveetha Dental College, Saveetha University, Chennai, Tamil Nadu, India

    Arthi Balasubramaniam

  4. Department of Conservative Dentistry & Endodontics, Saveetha Dental College, Saveetha University, Chennai, Tamil Nadu, India

    Sureshbabu Nivedhitha

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Contributions

Conceptualization, Susila AV. Data curation, Susila AV, Sai S, Nikita S, Veronica A and Nivedhitha S. Formal analysis, Susila AV and Sai S. Funding acquisition, not applicable. Investigation, Susila AV and Nivedhitha S. Methodology, Susila AV. Project administration, Susila AV. Resources, Susila AV, Sai S, Nikita S, Balasubramaniam A, Veronica A and Nivedhitha S. Software, Susila AV, Nivedhitha S and Balasubramaniam A. Supervision, Susila AV and Nivedhitha S. Validation, Susila AV, Nivedhitha S and Balasubramaniam A. Visualization, Susila AV and Sai S. Writing — original draft, Susila AV. Writing — review and editing, Susila AV and Sai S.

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Correspondence to Anand Venkatraman Susila.

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Key messages

• Castor oil, neem, garlic-lemon, noni and papaine have adequate antimicrobial activity.

• Post-operative pain is less for neem.

• Clinical and radiographic success is not different between papaine-chloramine, garlic extract and sodium hypochlorite.

• A combination of natural and synthetic agents like papaine-chloramine, neem-NaOCl and neem-CHX proved to be more effective than either of them alone.

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Susila, A.V., Sai, S., Sharma, N. et al. Can natural irrigants replace sodium hypochlorite? A systematic review. Clin Oral Invest 27, 1831–1849 (2023). https://doi.org/10.1007/s00784-023-04913-7

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