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Original Article
In vivo evaluation of zinc oxide‑propolis mixture as
root canal filling material in the primary molars: A
24-month follow-up randomized controlled trial
Kakarla Sri RojaRamya, C Vinay, K S Uloopi, Rayala Chandrasekhar
Department of Pedodontics and Preventive Dentistry, Vishnu Dental College, Bhimavaram, Andhra Pradesh, India
ABSTRACT
Background: Pulpectomy is a routine practice in
children with pulpal and periapical infections,
the success of which depends on the elimination
of bacteria from the root canals. Propolis, a
natural product with proven antibacterial and
anti‑inflammatory properties when mixed with
zinc oxide powder as root canal filling material,
it could provide good success in endodontic
therapy of primary teeth. Aim: The aim was to
evaluate and compare the clinical effectiveness
of zinc oxide‑propolis mixture with zinc oxide
eugenol  (ZOE) as root canal filling material in
nonvital primary molars. Settings and Design:
This was a 2-arm, parallel group randomized
controlled trial with blinded outcome assessment.
Materials and Methods: Forty primary molars
from children aged 4–8 years requiring pulpectomy
treatment were randomly allocated into two groups
according to the obturating material used: zinc
oxide‑propolis mixture (test group) and ZOE (control
group). All the pulpectomy treated teeth were
finally restored with stainless steel crowns, and the
children were recalled at 6, 12, and 24  months for
postoperative clinical and radiographic evaluation.
Statistical Analysis: Chi‑square test was used to
analyze the data. Results: The overall success rate of
pulpectomy with zinc oxide‑propolis mixture and
ZOE was found to be 95% and 70%, respectively, and
the difference was statistically significant (P = 0.037).
Zinc oxide‑propolis mixture has shown a success
rate of 100% at 6  months and 95% at 12 and
24 months follow‑up, whereas ZOE has shown 80%
success rate at 6 and 12  months, and it declined
to 70% at 24‑month follow‑up. Conclusion: Zinc
oxide‑propolis mixture demonstrated good clinical
and radiographic success at the end of 24  months,
and hence, it can be considered as an alternate root
canal filling material in the primary teeth.
KEYWORDS: Propolis, pulpectomy, primary teeth,
root canal filling material, zinc oxide, zinc oxide eugenol
© 2020 Journal of Indian Society of Pedodontics and Preventive Dentistry | Published by Wolters Kluwer - Medknow
Address for correspondence:
Dr. Kakarla Sri RojaRamya,
Department of Pedodontics and Preventive Dentistry, Vishnu
Dental College, Bhimavaram ‑ 534 202, Andhra Pradesh, India.
E‑mail: roja.ramya86@gmail.com
Access this article online
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DOI:
10.4103/JISPPD.JISPPD_127_20
Introduction
Nonvital pulp therapy procedure is a routine practice in
children to deal with pulpal and periapical infections,
the success of which depends on the elimination of
bacteria from the root canals. However, the complex
root canal system of the primary teeth makes it
difficult to achieve proper cleansing by mechanical
instrumentation and irrigation of the canals.[1]
Hence, obturating material having good antibacterial
properties is crucial and that will add to the better
prognosis of the procedure.
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For reprints contact: reprints@medknow.com
How to cite this article: RojaRamya KS, Vinay C, Uloopi KS,
Chandrasekhar R. In vivo evaluation of zinc oxide‑propolis
mixture as root canal filling material in the primary molars: A
24-month follow-up randomized controlled trial. J Indian Soc
Pedod Prev Dent 2020;38:171-6.
Submitted: 11-Mar-2020
Accepted: 11-May-2020 Published: 28-Jun-2020
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RojaRamya, et al.: Zinc oxide‑propolis mixture as root canal filling material in the primary molars
Various root canal filling materials for the primary
teeth have been tested from time to time; the
routinely used and readily available materials are
zinc oxide eugenol  (ZOE), calcium hydroxide, and
iodoform‑based pastes. ZOE is the widely used
obturating material. However, when eugenol in
the ZOE mix leaches out to the periapical tissues, it
causes irritation.[2] ZOE also has limited antimicrobial
action.[3]
In order to overcome some of the disadvantages of
currently available primary teeth root canal filling
materials, there is a continued interest to search for
better obturating material with broader and more
effective antibacterial action. Propolis is a natural
beehive product with potent antimicrobial[4] and
anti‑inflammatory properties.[5] The main chemical
constituents present in propolis are flavonoids,
phenolics, and other aromatic compounds. Considering
the beneficial properties of propolis, a clinical trial
was carried out to evaluate the effectiveness of zinc
oxide‑propolis mixture as root canal filling material in
the primary molars.
Materials and Methods
The study design is a 2-arm, parallel group
randomized controlled trial with 1:1 allocation
and blinded outcome assessment. The study
was approved by the institutional ethical board
(VDC/IEC/2014‑45) and is registered with the Clinical
Trials Registry‑India  (CTRI/2018/04/013313). The
experimental protocol is in compliance with the ethical
standards of the human experimentation, Declaration
of Helsinki. The study was conducted between July
2014 and July 2016. A  total of forty nonvital primary
molars indicated for pulpectomy in 4–8‑year‑old
children attending the outpatient department of
pediatric dentistry were included in the study, and the
children were followed up for a period of 24 months
after the therapy.
Eligibility criteria
Nonvital primary molars with extraoral or intraoral
swelling, sinus opening, Grade  I mobility due to
periradicular infection, and radiographic evidence
of minimum bone degeneration were included in the
study. The primary molars with less than two‑thirds
of the remaining root length, molars demonstrating
extensive external or internal resorption, and teeth
exhibiting greater than Grade  I mobility and are
nonrestorable with stainless steel crowns were
excluded from the study.
Primary outcome
Primary outcome is the success of zinc oxide-propolis
mixture and zinc oxide eugenol as root canal filling
materials in primary teeth at 6, 12 and 24 month follow-
up periods.
172 Journal of Indian Society of Pedodontics and Preventive Dentistry | Volume 38 | Issue 2 | April-June 2020 |
Sample size
The sample size was calculated setting the level of
significance at 5% and power 80%. Based on the
previous studies, to detect a difference of 25%, a
sample size of 20 per group is required including 10%
anticipated loss to follow-up.
Sequence generation and randomization
Randomization sequence was created using Excel 2007
with a 1:1 allocation using block randomisation of
block sizes 2 and 4 by an independent doctor.
Allocation concealment mechanism and
Implementation
The allocation sequence was concealed from the
investigator using sequentially numbered, opaque,
sealed and stapled envelopes. Generation of random
allocation sequence, enrollment and assignment
of participants to intervention were done by an
independent doctor who is not involved in the clinical
trial.
Blinding
Participants, outcome assessor and data analyst were
kept blinded to the allocation, whereas the operator
could not be blinded because of the recognizable
characteristics of the intervention materials
Interventions and Procedure
Prior written informed consent was obtained from
all the parents/legal guardians of the participating
children, and a total of forty teeth, comprising twenty
in each group were randomly allocated to either
test group (zinc oxide‑propolis mixture) or control
group (ZOE) by computer‑generated randomization.
In children allocated to test group, a patch test has
been done with propolis, and if found allergic, they
were excluded. Pulpectomy procedure was carried
out under strict aseptic conditions. The teeth were
isolated with rubber dam following local anaesthesia
administration. After removal of all the carious debris,
access to the pulp chamber was gained with #4 round
bur, and the necrotic pulp tissue was extirpated
using barbed broaches. Then, the working length was
determined, and the root canals were enlarged up to
the size 30–35 K files with intermittent irrigation using
1.5% sodium hypochlorite and normal saline.
If the tooth is asymptomatic, then the root canals were
dried with sterile paper points and filled 1 mm short of
the apex with zinc oxide‑propolis mixture (Zinc oxide
powder, Deepak enterprises, Mumbai, Maharashtra,
India; Brazilian Green Propolis alcohol free 60%,
Uniflora Health foods, Brazil) in test group and ZOE
(Zinc oxide powder, Deepak enterprises, Mumbai,
India; Eugenol, Prime Dental Products Pvt. Ltd., Thane,
Maharashtra, India) in control group using lentulo
spirals, and then, the access cavity was restored with
glass ionomer cement. All the teeth were finally restored
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RojaRamya, et al.: Zinc oxide‑propolis mixture as root canal filling material in the primary molars
with stainless steel crowns, and the participants were
instructed to report in case of any symptoms such as
pain or swelling. The patients were recalled at 6, 12,
and 24 months postoperatively. At each interval, teeth
were evaluated clinically and radiographically to grade
them as either success or failure.
The treatment outcome was considered successful
clinically when there is absence of pain, no tenderness
to percussion, absence or decrease in mobility and
sinus opening, and radiographically when there are
signs of resolution in the radiolucency, no new signs
of postoperative radiolucency, and no signs of internal
or external pathological root resorption demonstrated.
All the follow‑up evaluations were done by a blinded
clinician. Group allocation, follow‑up, and analysis
are reflected in CONSORT flow diagram  [Figure  1].
Radiographs of teeth treated with zinc oxide‑propolis
mixture and ZOE are illustrated in Figures  2 and 3,
respectively, which shows no pathological signs at any
of the follow‑up intervals.
Statistical methods
The collected data were entered into Microsoft Excel
sheet and were subjected to descriptive statistical
analysis using Chi‑square test in IBM SPSS Statistics
for windows, version 23 (IBM Corp., Armonk, New
York, USA). For all the tests, P ≤ 0.05 was considered
statistically significant.
Results
Participant flow through the trial is illustrated in
Figure 1. A total of 40 children, 20 in each group were
randomly assigned to zinc oxide-propolis mixture
group and zinc oxide eugenol group. All the children
received the interventions without any losses or
exclusions. Participants were recruited in July 2014 and
followed up till July 2016. The mean age of participants
was 6 years (range: 4 -8 years) with similar numbers of
boys and girls. There were no losses to follow-up at any
of the evaluation periods. The overall success rate of
pulpectomy with zinc oxide‑propolis mixture and ZOE
at the end of 24 months was found to be 95% (n = 19)
and 70% (n = 14), respectively, and the difference was
statistically significant (P = 0.037) [Table 1].
At 6‑month follow‑up, forty pulpectomy treated teeth
were available for evaluation, and no failures were
seen in zinc oxide‑propolis group, whereas ZOE group
has shown four failures. Zinc oxide‑propolis and ZOE
groups have yielded a success rate of 100%  (n  =  20)
and 80% (n = 16), respectively, and the difference was
statistically significant (P = 0.035) [Table 1].
At 12‑month interval, the success rate of zinc
oxide‑propolis group reduced to 95% (n = 19) with one
failure, whereas the success rate of ZOE remained the
same with no more failures, and the difference was
statistically not significant (P = 0.151) [Table 1].
Journal of Indian Society of Pedodontics and Preventive Dentistry | Volume 38 | Issue 2 | April-June 2020 |
Finally, at 24 months, no further failures were reported
in zinc oxide‑propolis group with the success rate
remaining same as 12‑month interval, whereas two
more failures were reported in ZOE group, and the
success rate reduced to 70% (n = 14) [Table 1].
Discussion
Endodontic therapy for infected primary dentition
aims to preserve the child’s health by maintaining
the deciduous teeth in a functional state until they
are replaced by permanent teeth. At present, the
most commonly used root canal filling materials for
the primary teeth are ZOE, calcium hydroxide, and
iodoform‑based pastes. Perhaps, none of the currently
available materials meet all the ideal requirements.
Concerns about the shortcomings of available
materials have led to a search for alternate root canal
filling materials for the primary teeth.
Propolis has gained the attention of researchers in
recent times because of its beneficial properties. It has
wide range of applications in the field of medicine
and dentistry. In dentistry, propolis has been used
for root canal irrigation,[6] direct and indirect pulp
capping,[7] reduction of dentin hypersensitivity,[8]
caries prevention against Streptococcus mutans,[9] and as
a storage media for avulsed teeth.[10]
In the present study, to confirm the presence of
functional groups in zinc oxide‑propolis mixture,
Fourier transform infrared spectroscopy was
performed. The spectrum of zinc oxide‑propolis
mixture showed the peaks at same wave numbers
as that of propolis, and this confirmed the presence
of functional groups  [Figure  4]. Zinc oxide chelates
with hydroxyl ions of the propolis, retaining all the
beneficial chemical classes of propolis in the set mix.
This, in turn, confirms that zinc oxide‑propolis mixture
retains all the beneficial properties of propolis.
ZOE has shown a success rate of 70% at the end of
24  months, and this was comparable to the success
rates noticed by Holan and Fuks, and Mortazavi and
Mesbahi.[11,12] At the end of 6 months, ZOE has shown
a radiographic failure in four teeth as an increase in
furcational radiolucency. Two more failures were
noticed at the end of 24  months in which one tooth
has shown an increase in furcational radiolucency and
the other tooth showed root resorption. These findings
suggest that the antibacterial efficacy of ZOE is short
lived.
Zinc oxide‑propolis mixture has demonstrated a
success rate of 95%, and a similar clinical success
rate of 93.8% at 12‑month follow‑up was observed by
Al‑Ostwani et al.[13] This success could be attributed to
the antibacterial,[4] antifungal,[14] anti‑inflammatory,[5]
and wound healing properties of propolis.[15] Several
studies have reported the significant antibacterial
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RojaRamya, et al.: Zinc oxide‑propolis mixture as root canal filling material in the primary molars

Figure 1: CONSORT flow diagram

a b c d
Figure 2: Radiographs of tooth 85 treated with zinc oxide‑propolis mixture; (a) Immediate postoperative radiograph; (b) 6‑month follow‑up
radiograph; (c) 12‑month follow‑up radiograph; (d) 24‑month follow‑up radiograph

a b c d
Figure 3: Radiographs of tooth 85 treated with zinc oxide eugenol; (a) Immediate postoperative radiograph; (b) 6‑month follow‑up radiograph; (c)
12‑month follow‑up radiograph; (d) 24‑month follow‑up radiograph

Table 1: Treatment outcome at three follow-up intervals

Groups Follow-up intervals
6 months 12 months 24 months
Success Failure Success Failure Success Failure
Zinc oxide-propolis mixture 100% (n=20) 0% (n=0) 95% (n=19) 5% (n=1) 95% (n=19) 5% (n=1)
Zinc oxide eugenol 80% (n=16) 20% (n=4) 80% (n=16) 20% (n=4) 70% (n=14) 30% (n=6)
P 0.035 (S) 0.151 (NS) 0.037 (S)
Chi-square test. S=Significant; NS=Not significant

efficacy of propolis against Enterococcus faecalis, galangin, and pinocembrin), caffeic acid, benzoic acid,
S. mutans, and Lactobacillus.[14,16] Flavonoids (quercetin, and cinnamic acid in propolis probably act on the

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RojaRamya, et al.: Zinc oxide‑propolis mixture as root canal filling material in the primary molars

microbial cell wall, causing functional and structural
damage.[17]
Previous studies have reported the antifungal activity
of propolis against Candida albicans.[14,18] Flavonoids
and phenolic acids in propolis damage the integrity of
yeast cell wall.[19] Propolis also has anti‑inflammatory
effect which suppresses the synthesis of prostaglandin,
leukotriene, histamine, and transforming growth factor
beta.[20] This anti‑inflammatory property of propolis
could further enhance the healing of the periapical
tissue and provides postoperative comfort. Arginine,
Vitamin C, provitamin A, B complex, copper, iron,
zinc, and bioflavonoids in propolis also assist in faster
wound healing.[21]
Zinc oxide‑propolis mixture has shown a failure in
one tooth in which root resorption was observed at the
end of 12 months, and no more failures were observed
at 24‑month interval. The overall success rate with
zinc oxide‑propolis mixture was found to be superior
compared to ZOE as root canal filling material.
Although the success rate of zinc oxide‑propolis
mixture in this study was quite promising, clinical
studies with long‑term follow‑up and large sample
size are warranted to reach sound conclusions.
Conclusion
Zinc oxide‑propolis mixture has demonstrated
good clinical and radiographic success as root canal
filling material in the primary molars at 24‑month
follow‑up. This outcome was found to be superior
compared to ZOE at all the time intervals. Hence, zinc
oxide‑propolis mixture can be considered as better
alternative to conventional ZOE mix, wherein eugenol
causes irritation to periapical tissues.

b
Figure 4: Fourier transform infrared spectra; (a) Fourier transform infrared spectrum of propolis; (b) Fourier transform infrared spectrum of zinc
oxide‑propolis mixture

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RojaRamya, et al.: Zinc oxide‑propolis mixture as root canal filling material in the primary molars
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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