The healing process of a surgical site after dental extraction is influenced by multiple factors, including host response, oral microbiota, extraction technique, smoking, systemic health conditions, and oral hygiene. ¹ Dental extractions can result in damage to the bone and soft tissue, negatively impacting the patient's quality of life and often leading to complications such as bleeding, pain, swelling, trismus, and infections. ² Although antibiotics and analgesics are routinely prescribed post-extraction, patients still frequently report discomfort during the recovery period. Researchers have explored various strategies and medications to reduce this postoperative discomfort, to find a simple yet effective method for providing an uneventful healing period.

One commonly available herb that has been investigated for its healing properties is turmeric (Curcuma longa), which contains a beneficial component called curcumin (diferuloylmethane). Curcumin has been found to possess anti-inflammatory, antimicrobial, anticarcinogenic, antimutagenic, antifibrotic, and antiaging properties. ³ Systemic C. longa extracts have been extensively studied in a variety of clinical conditions such as osteoarthritis, diabetes mellitus, and radiation dermatitis. ⁴ Curcumin has also been used orally and topically to treat oral diseases. ⁵ A triple-blinded randomized controlled trial demonstrated a reduction in plaque index and disease activity in patients with chronic periodontitis who were administered a mouthwash of essential oils and curcumin. ⁶ Systemic and topical turmeric has also shown benefits in oral submucous fibrosis by decreasing the burning sensation and increasing the mouth opening. ⁷

Mitic et al. evaluated the role of topical curcumin in the healing extraction socket of rats through biochemical assays and histopathological examination. They reported a decrease in myeloperoxidase and nitric oxide activity, which are inflammatory biomarkers. The same study also found a significant reduction in inflammatory cells and increased collagen production at the microscopic level, indicating the positive effects of topical curcumin in extraction wound healing. ⁸ Lone et al., in their randomized controlled trial, displayed a positive effect of turmeric in reducing pain and promoting healing for the management of dry sockets. ⁴ Although studies have demonstrated the beneficial healing potential of oral systemic curcumin for various dental conditions, including postoperative management following third molar surgery, ⁹ there is limited evidence testing the effects of topical C. longa in the management of pain and healing after routine dental extractions.

In this split-mouth randomized controlled trial, the primary aim was to evaluate the effectiveness of C. longa gel in reducing pain and promoting wound healing after dental extraction. The study's secondary objective was to assess the occurrence of dry sockets in patients treated with C. longa gel. The authors posited that the topical use of C. longa would decrease pain and inflammation due to its anti-inflammatory properties.

This study was a split-mouth randomized controlled trial conducted at the oral and maxillofacial surgery department over 3 months. The Institutional Ethics Committee approval (REF: IEC/20/FEB/157/17) and informed consent from all participants were obtained before the study. Clinical trial approval was also obtained and registered (Clinical trial registration no: CTRI/2021/05/033886).

Selection criteria

A total of 21 patients with bilateral extractions, excluding central and lateral incisors, were included in the trial, resulting in 42 extraction sites. The sample size was calculated as 25 per group. Patients with periapical pathology on a radiograph, pregnant and lactating women, those taking antibiotics or analgesics/anti-inflammatory drugs in the past 14 days, and those with a known allergy to C. longa were excluded.

Procedure

Patients with bilateral extractions meeting the criteria were included in the study. Written informed consent was obtained, and bilateral extractions were performed after administering local anesthesia using 2% lidocaine HCl with 1:200,000 epinephrine under aseptic precautions. All extractions were performed by a single oral and maxillofacial surgeon. Bilateral extraction sites were randomly assigned to two groups using a simple randomization technique through a lottery method. The test group had the extraction socket packed with gel foam coated with C. longa gel (Curenext Oral Gel by Abbott Healthcare Pvt., India), while the contralateral socket (control) was packed with plain gel foam as a placebo. Patients were prescribed diclofenac 50 mg and amoxicillin 500 mg 8 hourly for 3 days postextraction and were instructed to avoid other medications during the study. Follow-up evaluations were scheduled on the 3 ^rdand 7 ^thday.

Outcome measurements

Patients were evaluated on postoperative days 3 and 7 to assess pain, wound healing, and complications. The pain was evaluated using the Numerical Pain Scale, which measures pain on a scale from 0 to 10, with 0 indicating no pain and 10 indicating the worst possible pain. Wound healing was evaluated using a scale provided by Landry et al. ¹⁰ Table 1, which estimates healing with five levels of scores evaluated using four parameters: tissue color, response to palpation, granulation tissue, and incision margins. A single investigator performed all the clinical examinations and was blinded to the test and control side.{Table 1}

Statistical analysis

Statistical analysis was performed using the SPSS software version 19. Descriptive statistics were employed to estimate mean, standard deviation, and percentages. Both the outcomes of pain and healing were assessed on Likert scales. Since the Likert scale can be treated as continuous data, parametric tests were employed. The paired t-test was employed to assess the changes in the outcomes on the 3 ^rdand 7 ^thdays within each group. The unpaired t-test was used to compare the outcomes between the study and the control groups. The statistical significance was fixed at P ≤ 0.05.

The study enrolled 21 participants with 42 extraction sites, of which 62% were female and 38% were male, with a mean age of 56 years. The mean pain scores and mean healing scores were calculated for the test and control groups on the 3 ^rdand 7 ^thdays. Both groups showed an overall improvement in pain and healing, with lower mean pain scores on day 7 compared to day 3 and higher mean healing scores on both days Table 2. The mean healing scores were significantly higher in the test group than in the control group on the 3 ^rd(3.52 vs. 2.86; P: 0.036) and 7 ^thdays (4.32 vs. 3.62; P: 0.018). On day 7, the mean pain scores were significantly lower in the test group compared to the control group (0.8 vs. 1.7; P: 0.05) Table 3. No cases of dry sockets were observed in either group.{Table 2}{Table 3}

C. longa L. or turmeric or “Indian Saffron,” a plant belonging to the ginger family, is known for its medicinal properties with a history dating to nearly 4000 years. It has gained recent attention in modern medicine, reflected by more than 3000 publications in the past 25 years. Turmeric contains three curcuma longaoids: C. longa, demethoxycurcuma longa, and bisdemethoxycurcuma longa. ¹¹ In vitro studies have proven that C. longa is a potent anti-inflammatory, antioxidant, antimutagenic, anticarcinogenic, and antimicrobial. ¹² This antioxidant property is essential for wound healing as the presence of reactive oxygen species for a longer duration is known to retard the healing process. ⁸ Several mechanisms have been proposed for the anti-inflammatory actions of C. longa, one of them being downregulation of NF-κB. Numerous studies have investigated the anti-inflammatory role of C. longa in diseases such as arthritis, Alzheimer's, and metabolic syndromes.

The current study evaluated pain and wound healing in extraction sockets treated with C. longa gel compared to the placebo-treated contralateral socket. Both pain and wound healing are affected by multiple variables; of which the individual patient response is one of the important factors. ¹³ To eliminate these patient-dependent confounders, the authors selected a split-mouth design for the study. Since the teeth along the midline receive innervations from both the right and left sides, central and lateral incisors were excluded from the study to facilitate a clear distinction between right and left extraction-site pains.

The process of healing that follows an extraction of teeth includes inflammation, cell proliferation, matrix deposition, and remodeling. During the initial phase of healing, the inflammatory mediators are primarily responsible for the pain and discomfort. ² C. longa with its anti-inflammatory properties, may aid in reducing these symptoms. Oral C. longa has low bioavailability due to extensive first-pass metabolism. ¹² Thus, topical C. longa was deployed in this study.

On day 3 and day 7 after the extraction procedure, the mean healing scores were higher and statistically significant on the side that received C. longa dressing than the control sides. Nagasri et al., in their study, found similar healing benefits of C. longa in patients with chronic periodontitis. ¹¹ Some studies evaluating the role of C. longa in gingivitis and periodontitis demonstrate the potential of C. longa in accelerating wound healing. ¹⁴ A recent study by Lone et al. demonstrated that C. longa is more effective in managing pain and inflammation associated with dry sockets than zinc oxide eugenol dressing. ⁵ However, no split-mouth studies are evaluating the healing of extraction sockets after C. longa application. This healing potential of C. longa can be attributed to many factors. Various studies have proven that C. longa increases regeneration of the epithelium, promotes fibroblast proliferation, and enhances vascular density. ³ Recent evidence also implicates the role of C. longa in wound contraction and tissue remodeling. Due to its anti-inflammatory potential, it decreases edema and vascular engorgement of oral tissues. ¹⁵ , ¹⁶ , ¹⁷

Less pain intensity was reported on the C. longa side than on the placebo side. Our findings were similar to the study by Maulina et al. The randomized controlled trial by Maulina et al. included 90 participants, divided into two groups; one of which consumed mefenamic acid and the other consumed oral curcumin capsules. The curcumin group had significantly less postoperative pain compared to the mefenamic group, concluding systemic curcumin to have a significant role in reducing acute inflammation following extraction. ⁹

A few limitations need to be considered while interpreting the current study's findings. An absolute patient blinding may have been compromised due to the difference in the color of the dressings on the test and control sides. Studies with larger sample sizes are required to further potentiate this evidence.

The primary and secondary objectives were accomplished in the current study

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Conflicts of interest

The authors of this manuscript declare that they have no conflicts of interest, real or perceived, financial or non-financial, in this article.