View of The Effectiveness of Natural Virgin Coconut Oil in Periodontal Tissue Regeneration

The Effectiveness of Natural Virgin Coconut Oil in Periodontal Tissue Regeneration

Hasanuddin Thahir¹, Sri Oktawati¹, Harun Ahmad², Rasmidar Samad^3, Ayu Rahayu Feblina⁴, Afdalia Annisa⁴, Nir Etriyani^4,

1Lecturer of Periodontology Department, Faculty of Dentistry, HasanuddinUmiversity, Indonesia

2Lecturer of Pediatric Dentistry Department, Faculty of Dentistry, Hasanuddin University, Indonesia

3Lecturer of Public Dental Health Department, Faculty of Dentistry, Hasanuddin University, Indonesia

4Periodontolgy Specialist Educational Program of DentistryFaculty, Hasanuddin University, Indonesia Corresponding Author: [email protected]

ABSTRACT

Background: Periodontal disease is the most common inflammatory disease presents in humans. Data from Global BurdenofDiseasein 1990-2010 shows that periodontal disease, particularly periodontitis, ranks sixth globally with percentage of 11.2% and suffered by approximately 743 million people. While in Indonesia according to the data from RISKESDAS 2018, the prevalence of periodontitis reached 74.1%

of the total number of oral diseases experienced by the population. Coconut plant (Cocosnucifera L) has great potential to be processed into useful products. Virgin Coconut Oil(VCO)formed by processing coconut flesh into oil is used as medicine and believed to to cure various diseases. The advantage of this oil lies in the high level of saturated fatty acids (around 90%), which makes VCO the healthiest oil. VCO is very rich in lauric acid content, ranging 50-70%, which gives VCO a tissue regeneration effect.

Objective: This study aims to discuss the effectiveness of VCO on the regeneration of periodontal soft tissue in periodontitis.Method: A systematic study was conducted on the PubMed and Google Scholar databases for clinical trials published in English up until 2021. A preliminary search of the databases resulted in 110 articles. Manual searches of full text articles and other related articles were carried out afterwards. PICO (Population, Intervention, Control, and Outcomes) questions were used in this systematic review. The articles selected were those that focused on the effectiveness of VCO on tissue healing and regeneration.Literature Review: Virgin Coconut Oil is proven to speed up wound healing time and has the highest healing rate, due to its ability to moisturize wounds, accelerate cellular metabolism, and has the anti-inflammatory and anti-infection properties in treating chemical burns. VCO with its high lauric acid content cqan accelerate the tissue regeneration process, where regeneration is often used to describe the formation of new adhesions, cementum, alveolar bone and periodontal ligaments on the site that has previously lost the tooth-supporting tissue structure. Regeneration will result in the replacement of the damaged tissue with the same newly-fomed tissue.

Conclusion: Is proven to provide many benefits for daily life, especially in the health sector. Lauric acid, which is abundant in VCO, can stimulate soft tissue that is damaged due to inflammation, also accelerates wound and tissue healing.

Keyword:Virgin Coconut Oil, Regenerative Theraphy, Periodontitis INTRODUCTION

Periodontitis is one of the most common dieases in Indonesia, based on the results of the 2018 Ministry of Health’s RISKESDAS study, the prevalence of periodontitis reached 74.1%

(Ministry of Health 2018). Periodontitis is a periodontal disease characterized by inflammation

of the tissues supporting the teeth. Periodontitis progression is generally caused by plaque bacteria on the tooth surface, where plaque is a thin layer of biofilm containing a cluster of pathogenic microorganisms.^(1,2)Periodontitis if not handled properly, then the interaction between plaque bacteria, their products and the body’s response can trigger an inflammatory response that can cause ulceration of the gingiva, damage on connective tissue, loss of alveolar bone, and eventually tooth loss.⁽³⁾

As a country with tropical climate, Indonesia is able to produce roughly 18,3 tons of coconuts each year. Virgin Coconut Oil (VCO) is a popular coconut product that possesses many benefits, made from fresh coconut meat, processed at low temperature to produce a product with low content of water and free fatty acids, is transparent, fragrant, and has a long shelf life of up to 12 months.^(4,5) VCO contains lauric acid and caprylic acid (6-7%) which have the ability to kill bacteria and viruses. Lauric acid in VCO is converted into monolaurin which has antiviral, antibacterial and antiprotozoal properties.⁽⁶⁾Lauric acid in VCO also has the effect of stimulating fibroblast cells by fibronectin. Lauric acid is associated with the activation of transforming growth factor beta (TGF-β), which is a proliferating growth factor that stimulates fibronectin in the formation of fibrin threads and clots. In a research conducted by Jannahet al., The Effect of Virgin Coconut Oil Application on Increasing the Number of Fibroblasts in Post Tooth Extraction Wounds in Rattusnovergicus, showed an increase in the number of fibroblasts in wounds after tooth extraction performed in Rattusnovergicus, in which the wound was treated with oral VCO, and VCO was able to increase fibroblasts 0.4 times greater than povidone iodine.⁽⁵⁾

METHOD DATA SOURCE

Data search using Google Scholar and Pubmed with English keyword was carried out to determine the research protocol. The search was done to identify articles published in dental journals that focused on VCO and soft tissue therapy. The keywords used were VCO, Periodontitis, and Tissue Regeneration. Search filters were applied to the electronic search to display only English studies that provide full-text articles. Manual searches of published full-text articles and related literature reviews were carried out afterwards.

The inclusion criteria used for this review are English full-text articles published between 2016- 2021 and are related to the effect of VCO on periodontal soft tissue regeneration. Meanwhile, the exclusion criteria were articles in the form of systematic reviews, blogs, textbooks, and meta- analysis.

DATA COLLECTION

The data used in this literaturerevieware secondary data. The data were obtained from articles which were then reviewed based on the criteria determined by the authors.

RESULT

After 110 articles were gathered from Google Scholar and Pubmed searches, 66 articles were excluded because they did not meet the criteria desired by the authors, leaving 36 articles that were then reviewed based on their titles and abstracts, after which 27 articles were excluded because they did not match the inclusion criteria. Finally, 9 articles were obtained, reviewed and then entered into the synthesis table.

Records identified through database searching (PubMed) (n= 2)

Additional records identified through other sources (google cochrane) (n=108)

Records screened by titles and abstracss (n=27)

Full-text articles assessed for eligibility (n=9)

Articles agreed for inclusion in the review

Records excluded (n=66)

Full-text articles excluded, with reasons (n=37 ) ide

ntifi cati on

incl ude d scre

eni ng

eligi bilit y

Table1. Effect of VCO gel application on periodontal soft tissue regeneration N

o

Journal reference Method Result

1 FrancescaRipari (2020)

The RoleofCoconut Oil in TreatingPatientsAffectedbyPla que-Induced Gingivitis: A Pilot Study.⁽⁷⁾

Materials andMethods The sampleof 20

patientswasdividedintotwo groups: the study

groupandthecontrolgroup.

In the study group, coconutoil, in theformofmouthwash, wasadministeredto a sampleofpatientswith gingivitis, agedbetween 18 and 35. The

protocolestablished a dailyapplicationoftheprodu ctfor 30 days, in

whichtheclinicalparameters forplaqueformationand gingivitis were

measuredbytheplaqueindex ( PI), bleedingindex (BI).

The controlgroupdid not associatethecoadjuvantwith normal daily oral

hygieneproceduresandthesa meclinicalparameters were evaluatedat t0 andafter 30 days (t1).

Based on the data collected showed a significant improvement in reducing plaque formation and gingivitis

2 Sandeep R. Varma (2017)

In vitro anti-

inflammatoryandskinprotectiv epropertiesof Virgin

coconutoil.⁽⁷⁾

Cell lines and its maintenance, chemicals, gas chromatography-FID analysis, cell viability, ELISA for cytokine measurement, ELISA for involucrin and filaggrin, semi-quantitative RT-PCR, skin irritation and

phototoxicity assay, UV inhibitory study by reactive oxygen species assay.

The study showsthe anti-

inflammatoryactivityof VCO that

suppressesinflammatorymarkersandprotectsthes kinbyenhancingtheskin’sprotectivefunction.

3 Ratna sari dewi. atall (2017)

Effectof 12.5%

virgincoconutoilonporphyrom onasgingivalisandtreponema denticolabacterialcolonization .⁽⁸⁾

23 subjects, were patientswith posterior porcelain-fused-to-metal crownvisiting

FacultyofDentistyUniversit as Indonesia dentalhospital.

Patients

signedtheinformedconsent and

clinicalperiodontalexaminat ion was donePatientswere

The use of 12.5% virgin coconut oil showed a decrease in the number of P. gingivalisandT.

denticolaon the margin of the porcelain-fused- to-metal crown.

asked

togargletwicedailywith 12.5%virgincoconutoil, 30cc for 1 min in 4days.

Saliva samples

werecollectedwithpaperpoi ntto calculate the number of P. gingivalisandT.

denticolausingreal- timepolymerasechainreacti on.

4 Ummi Aqilah Haron.atall (2017)

The

ComparativeAntimicrobialEffe ctofActivated Virgin Coconut Oil (AVCO) and Virgin Coconut Oil (VCO) against Dental Caries-

RelatedPathogens.⁽⁹⁾

In this study, the

researchers compared the antimicrobial effect of AVCO obtained from KL trading, Selangor, Malaysia, and VCO extracted in their own laboratory. TheMIC and MBC of each coconut oil against the selected dental caries-related pathogen;

Streptococcus mutans, Lactobacillus casei and Candida albicans were determined.

In contrastto a positivefindingof AVCO, VCO has shownnoinhibitoryeffectonalltested dental caries-relatedpathogens. Furthermore, thetimekillingassayrevealedthat AVCO showedrelativelyquick-killingactivityatthe 8 hoursoftimeforalltestedorganism.

Thesefindingcorrelateswiththatof AVCO possessbactericidalactivity,

therebyallowingthepossibleclassificationofthe AVCO as being a bactericidalagent.

5 PRIMA ABIGAIL Gayatri (2019)

StabilityOfZoledronate Gel Emulsion In Virgin Coconut Oil.⁽¹¹⁾

ZOL gel

emulsionconsistsof 0.16%

ZOL powder, 2%

carboxymethylcellulose, 5% VCO, 0.44% sodium benzoate, and 0.009%

antioxidanthydroxytoluene, anddistilledwater. This gel emulsionsamplewasstoreda t 25 ° C and 40 ° C for 1 month,

andtheparametersusedforth estabilitytest were pH, viscosity, spreadability, andadhesivestrength. ZOL gel

emulsionwasevaluatedagai nstthismetricondays 1, 7, 14, and 28.

This study foundthatthe ZOL gel emulsionwasstablewhenstoredat 25 ° C.

Organolepticvalues, pH, viscosity, dispersibility, andadhesivestrength were alsostable, anddegradationwasconstant.

6 Siti Fatimah BintiRahmat(2018)

Virgin Coconut Oil, Coconut Milk And Coconut Water Potential Inthe

RemineralizationOf Tooth Enamel Surface.⁽¹²⁾

The

researchwasstartedbyanalyz ingtheelementalcontentof VCO, CM, and CW using ICP-MS.

Followingtheevaluationof enamel remineralization, thespecimens were observedunder a

scanningelectronmicroscop

In general, this study aims to determine the potential of virgin coconut oil (VCO), coconut milk (CM), and coconut water (CW) as new alternatives in remineralizing the surface of tooth enamel.

The results showed that VCO and CM left a protective layer over the enamel surface, while the control did not show any changes in the enamel surface morphology.

e. The specimens were demineralizedusing a demineralizationsolutionatp H 4.01 for 7

daysthenreactedwith VCO, CM, and CW as

remineralizationsolutionsfo r 14 days.

Distilledwaterwasused as a controlduringthe study.

Observationsusing SEM / EDX.

7 Putri Dafriani, et al(2020)

Virgin Coconut Oil (VCO) AcceleratedWoundHealingPro cess in Diabetes mellitus (DM) PatientsWithDiabeticUlcer in dr. Rasidin Hospital, Padang, Indonesia.⁽¹²⁾

This research is a quasi- experimental research carried out in the Inpatient Installation of Dr. Rasidin Hospital Padang, West Sumatera, Indonesia. The study participants were diabetic ulcer patients who were divided into 2 groups, 8 patients in the control group and 8 patients in the intervention group. The control group was given wound care using 0.9%

NaCl and the intervention group was treated with 0.9% NaCl plus VCO.

There were significant differences in the wound surface between the control group and the intervention group. VCO helps wound healing by reducing the surface area of the wound.

8 Jansen Silalahi, et al (2019)

The Activity of Hydrolyzed Virgin Coconut Oil to Increase Proliferation and Cyclooxygenase-2 Expression towards on NIH 3T3 Cell Line in Wound Healing Process^.(13)

The sampleusedwas Virgin Coconut Oil (VCO). VCO waspartiallyhydrolysedusin g lipase

fromRhizomucormieheito producehydrolysed VCO (HVCO)

composedoffreefattyacids, 2-monoglycerides.

Thenacidvaluewasdetermin ed. The effectof HVCO onproliferationwasevaluate dusingthe MTT method.

Woundhealingassaywasesta blishedby a

cellmigrationmethod, and COX-2

expressionwasdeterminedu sing RT-PCR.

HVCO is proven to be effective in increasing cell proliferation and wound healing process.

The activity of Hydrolized Virgin Coconut Oil increases the proliferation and expression of Cyclooxygenase-2 against the NIH 3T3 cell line in the wound healing process.

9 Dian Ika Perbina Meliala, etal

(2019)

The Role of Coconut Oil to

Coconutoilused in this study wasvirgincoconutoil (VCO) and VCO

hydrolysedbyRhizomucorm iehei (HVCO). NIH 3T3 cells (5x10⁵cells/well) were

VCO and HVCO increasetheexpressionof MMP-9, PDGF-BB, dan TGF-β1 in NIH3T3 cellsandtherefore, coconutoilactive in thewoundhealingprocess. HVCO ismorethanactivethan VCO.

Increase Expression of MMP- 9, PDGF-BB, and TGF-β1 in NIH-3T3 Cell Line.⁽¹⁴⁾

seeded in

ninewellsandincubatedforo vernight,

thendividedintothreegroups .

Eachgroupconsistedofthree wells. Group

onewithouttreatment, grouptwoadded VCO, andgroupthreeadded HVCO

andthenincubatedforoverni ght. One well in

eachgroupwasadded MMP- 9, PDGF-BB, and TGF-β1 andincubatedonehour.

Finally, expressionsof MMP-9, PDGF-BB, and TGF-β1 were

detectedusingimmunocytoc hemistrymethod.

LITERATURE REVIEW Periodontitis

Periodontitisis defined as an inflammatory disease of the tooth-supporting tissue, caused by certain microorganisms where these organisms produce a number virulence factors and induce host inflammatory mediators, causing inflammation that extends into the tissue and potentially resulting in progressive damage to the periodontal ligament and alveolar bone with increased probing depth, recession, or both, causing mobility and eventually tooth loss. The severity varies between individuals, regardless of the degree of bacterial infection, suggesting that a regulated host inflammatory response may contribute to the presence of microorganisms.^(16–18)

Etiology of Periodontitis

The etiology of periodontitis comes from a group of bacteria, especially gram-negative and anaerobic bacteria, which colonizes the sub-gingival region. Specific bacteria such as Porphyromonasgingivalis,Tannerelaforsythia, Treponemadenticola, Aggregatibacteractinomycetemcomitans, Prevotellaintermedia, Fusucobacteriumnucleatum, which to this day is termed “Red complex” bacteria (P. gingivalis, Tannerellaforsythia,

Treponemadenticola) are the primary etiological factor in periodontal disease, specifically most common in chronic periodontitis.^(18,19)

Pathogenesis of Periodontitis

The pathogenesis of periodontitisinvolves not only microorganisms in plaque, but also several factors associated with the host. In the early stages of periodontitis, inflammation occurs in gingiva as a response to bacterial attack. Red complex bacteria will triggers the immune response, namely neutrophils, macrophages, lymphocytes in the gingival tract, to fight against periodontal pathogens and endotoxins, maintain the host tissue and control the bacterial development.⁽²⁰⁾

The mechanism of tissue damage occurs through immune response, and is not a direct consequence of bacteria presensce. Macrophages are not the dominant feature in advance lesions, where they only account for 5% of the cells. Fibroblasts when stimulated by the inflammatory cytokines IL-1, IL-6, TNF-α, PGE2, will produce Matrix Metalloproteinases (MMPs) which is a family of proteinases that aims to degrade the extracellular matrix. Collagen molecules are broken down into smaller ones, which are then denatured in the extracellular environment or phagocytosed by surrounding fibroblasts.⁽²⁰⁾

Treatment for Periodontitis

Treatment for periodontitis generally falls into two categories: 1) Procedures to stop the progression of the disease, namely the initial phase therapy consisting of scaling, root planing, oral hygiene improvement, and occlusal adjustment if needed. 2) Procedures to regenerate structures damaged by the disease. Supportive maintenance of periodontal therapy after active treatment is essential to achieve maximum results. Attempts to suppress the subgingival microbiota as much as possible, supports the repair and regeneration of the periodontium. In various short- and long-term clinical studies, the administration of drugs combines with supragingival plaque control has proven to be effective.^(21,22)

Tissue Regeneration

Regeneration is the process of regrowing and reconstructing tissue from a lesion, to restore the initial shape and function of the tissue affected by the lesion. Regeneration oftentimes used to

describe new formation of cementum, adhesions, alveolar bone and periodontal ligamentumon the surface where the tooth-supporting tissue structure is missing. Regeneration will result in replacement of the damaged tissue with the same tissue structure. In periodontal tissue, the damaged epithelium is replaced by epithelium, whereas connective tissue and periodontal ligaments is replaced by connective tissue.⁽²³⁾

Virgin Coconut Oil (VCO)

Coconut oil is rich in medium-chain fatty acids and shows good digestibility (Che Man &

Marina, 2006). The term VCO refers to oil obtained from fresh and ripe raw coconut fruit, mechanically or naturaly, with or without the use of heat, and without chemical refining (Villarino, Dy, &Lizada, 2007). Unlike RBD (Refining, bleaching, anddeodorizing) coconut oil which is specially made for cooking purposes, VCO is currently being marketed as functional oil. Since it was first introduced, virgin coconut oil has attracted the public attention. Information about the beneficial properties of VCO spreads rapidly.⁽²⁴⁾

Current researches have shown that VCO has the ability to moisturize wounds, accelerate cellular metabolism, and has the anti-inflammatory and anti-infection properties in chemical burns. Virgin coconut oil has been shown to speed up wound healing time and has the highest percentage of healing effect on chemical burns in RattusNovergicus. Research conducted on 18 Sprague-Dawley with excision wounds, proved that VCO was able to increase fibroblasts proliferation so that the density of collagen fibers increased, and helped accelerate the tissue regeneration process.^(5,25)

DISCUSSION

Indonesia is a country with the largest coconut plantation area in the world, reaching 3.7 million ha. The coconut plant has many benefits from its roots, stems, leaves, fruit, to the midrib.⁽²⁶⁾ Virgin Coconut Oil (VCO) is produced from processed coconut flesh which is known to have the ability to moisturize wounds, accelerate cell metabolism, and has the anti-inflammatory and anti- infection properties in treatment of chemical burns. VCO has been shown to speed up wound healing time and has the highest percentage of healing against chemical burns in Rattusnovergicus. Research conducted on Sprague-Dawley mice with excised wounds proved that VCO was able to increase fibroblasts proliferation, thus increased the collagen fibers density

and helped accelerate the tissue regeneration process.^(27,28)Similar result was also shown in a study conducted by Ratna Sari et al. (2017) where the number of P. gingivalisand T.

denticolawere decreased after gargling with 12.5% VCO for 4 days.^(6,8)

Regenerativetherapy is a field of biotechnology that combines various aspects and treatment strategies, including the use of cells produced, in order to increase, restore, or replace a damaged or missing tissue, effectively repairing the tissue both structurally and functionally. Regenerative medicine includes the use of growth factors, biomaterials, and stem cells.^(29,30)In periodontal tissue, regeneration is a continuous physiological process, in which under normal conditions new cells and tissues are constantly being formed to replace mature and dead cells and tissues.⁽³¹⁾ The Medium ChainTriglyceride(MCT) content in VCO in the form of lauric acid, flavonoids, and tocopherol, is anti-inflammatory and can prevent infection and excessive cell damage. Lauric acid in VCO is also associated with the activation of TGF-β cytokines which will stimulate fibronectin in fibrin clots formation, which then become the framework for re-epithelialization and proliferation of fibroblasts, which can accelerate the healing process in inflammation.⁽⁵⁾Research conducted by Jansen Silalahi (2019), by applying VCO topically to wounds, obtained faster healing as indicated by decreased epithelialization time, increased fibroblast proliferation, and higher collagen turnover resulted in faster wound healing.^(13,25)Research conducted by PutriDafriani (2020) on inpatients with diabetes mellitus ulcers, compared the administration of 0.9% NaCL and NaCl combined with VCO, the results then showed a reduction in wound surface area in the combination group of NaCl and VCO, which proved that VCO has an effect on dermal and epidermal healing, and provides strength to the epithelial tissue.(12,32,33,34,35,36,37)

In a trial done by Dian IkaPerbinaMeliala, et al. (2019), the use of Virgin Coconut Oil (VCO) and VCO hydrolyzed with Rhizomucormiehei(HVCO) resulted in the increased expression of MMP-9, PDGF BB, and TGF-1β in NIH3T3 cells, suggested that coconut oil is active in the wound healing process. Whereas in the study conducted by UmmiAqilahHaron, et al. (2017), VCO has shown no inhibitory effect on all tested dental caries-related pathogens. Furthermore, the time killing assay revealed that AVCO showed relatively quick-killing activity at the 8 hours of time for all tested organism. These finding correlates with that of AVCO possess bactericidal activity, thereby allowing the possible classification of the AVCO as bactericidal agent.^(9,14)

CONCLUSION

Periodontitis can cause damage to both the soft and hard tissues in the oral cavity. VCO is believed to provide many benefits for daily life, especially in the health sector. Lauric acid, which is abundant in VCO, can stimulate soft tissue that is damaged due to inflammation.

Further and detailed research is needing regarding the benefits of VCO in healing inflamed tissue.

REFERENCES

1. Andriani I,, Chairunnisa FA. Periodontitis Cronicand Management Case with Curretage. Insisiva Dent J. 2019;8(1):25–30.

2. A. AET, M. A, Abd El-Hamid M, El-Dessouky E. Virulence Genotyping of Enterococcus species isolated from meat and milk products. Benha Vet Med J. 2016;31(2):158–64.

3. Graziani F, Karapetsa D, Alonso B, Herrera D. Nonsurgical and surgical treatment of periodontitis: how many options for one disease? Periodontol 2000. 2017;75(1):152–88.

4. Ramlan Silaban, Riza Sahala Mnullang VH. Processing Virgin Coconut Oil (VCO) ThroughCombinationTechniqueFermentationand Enzimatis UsingPineapple Extract. J Kim [Internet]. 2014;56–64. Available from: http://digilib.unimed.ac.id/11906/

5. Jannah Tamara AH, Rochmah YS, Mujayanto R, Hibah A, Tamara J, Rochmah YS, et al.

Influenceof Using Virgin Coconut Oil toIncreased FibroblastCell in Healing Post Extraction in Rattus Novergicus. J Medical. 2015;1(2):29–33.

6. Peedikayil F, Sreenivasan P, Narayanan A. Effect of coconut oil in plaque related gingivitis - A preliminary report. Niger Med J. 2015;56(2):143.

7. Varma SR, Sivaprakasam TO, Arumugam I, Dilip N, Raghuraman M, Pavan KB, et al. In vitro anti-inflammatory and skin protective properties of Virgin coconut oil. J Tradit Complement Med.

2019;9(1):5–14.

8. Dewi RS, Gita F, Bahtiar B, Kasim HB. Effect of 12.5% virgin coconut oil on porphyromonas gingivalis and treponema denticola bacterial colonization. Int J Appl Pharm. 2017;9(Special Issue 2):32–5.

9. Aqilah Haron U, Abllah Z, Mardia Mohamad Nasir NA. The Comparative Antimicrobial Effect of Activated Virgin Coconut Oil (AVCO) and Virgin Coconut Oil (VCO) against Dental Caries- Related Pathogens. 2018;(March).

10. Rahmadi A, Abdiah I, Dewi Sukarno M, Purnaningsih T. Characteristic ofPhysicochemicalandantibacterial of Virgin Coconut Oil result of BacteriaLactat Acid. J Technol.

2013;24(2):178–83.

11. Nevin KG, Rajamohan T. Effect of topical application of virgin coconut oil on skin components and antioxidant status during dermal wound healing in young rats. Skin Pharmacol Physiol.

2010;23(6):290–7.

12. Dafriani P, Nur SA, Morika HD, Marlinda R. Virgin Coconut Oil ( VCO ) Accelerated Wound Healing Process in Diabetes mellitus ( DM ) Patients With Diabetic Ulcer in dr . Rasidin. J Aisyah J Ilmu Kesehat. 2020;5(2):221–4.

13. Silalahi J, Yuandani Y, Meliala DIPB, Margata L, Satria D. The activity of hydrolyzed virgin coconut oil to increase proliferation and cyclooxygenase-2 expression towards on nih 3t3 cell line in wound healing process. Open Access Maced J Med Sci. 2019;7(19):3164–8.

14. Cell NIH, Ika D, Meliala P, Silalahi J, Yuandani Y, Margata L, et al. The Role of Coconut Oil to Increase Expression of MMP-9 , PDGF-. 2019;7(22):3733–6.

15. Kasliwal N, Nuwal P, Giri SS, Gupta S, Porwal V. Alternative Wound Healing Effects of Coconut Oil Extract Using Adult Wistar Rats. Int J Med Heal Prof Res. 2014;1(2):68–70.

16. Nayak A, Bhat K, Shivanaikar S, Pushpa P, Kugaji M, Kumbar V. Detection of red complex organisms in chronic periodontitis by multiplex polymerase chain reaction. 2018;5:139–44.

17. Rubim M, Sete C, Marcelo C, Sztajnbok F. Review article Periodontitis and systemic lupus erythematosus ଝ. Rev Bras Ortop (English Ed. 2015;(x x):6–11.

18. Reddy S. Essentials of Clinical Periodontology and Periodontics. Third. Jaypee Brothers Medical Publishers (P) Ltd; 2011.

19. Newman MG, Takei HH. Newman and Carranza ’ s Clinical Periodontology THIRTEENTH EDITION.

20. Tawfig N. Journal of Dental Problems and Solutions Proinflammatory Cytokines and Periodontal Disease. 2016;3:12–7.

21. Dr. Alexandrina L. Dumitrescu. Etiology and Pathogenesis of Periodontal Disease. London:

Springer Heidelberg Dordrecht; 2010.

22. Zandbergen D, Slot DE, Niederman R, Weijden FA Van Der. The concomitant administration of systemic amoxicillin and metronidazole compared to scaling and root planing alone in treating periodontitis : = a systematic review =. BMC Oral Health. 2016;1–11.

23. Manuel F, Illueca A, Vera PB, Cabanilles PDG, Fernandez VF, José F, et al. Periodontal regeneration in clinical practice. 2006;

24. Marina AM, Man YBC. Virgin coconut oil : emerging functional food oil. Trends Food Sci Technol. 2009;20(10):481–7.

25. Rajamohan KGNT, Nevin KG, Rajamohan T. Effect of topical application of virgin coconut oil on skin components and antioxidant status during dermal wound healing in young rats. Skin Pharmacol Physiol. 2010;23(6):290–7.

26. Widiyanti RA. Utilization of Coconut Into a VCO (Virgin Coconut Oil) as Antibiotics in an Effort to Support The Health Of Indonesian Healthy Vision 2015. 2015;577–84.

27. Andriani I, Chairunnisa F. Case Report Periodontitis

CronicandManagementCasewithCurretagebacteriausingmaterialtoxic. Dent J Insisiva.

2019;8(1):25–30.

28. Michael G. N, Takei H, R. Klokkevold P, Carranza F. Newman and Carranza’s Clinical

Periodontology 13th ed. 2018. 1573–1589 p. 329.

29. Tani PG, Wowor PM, Khoman JA. Indibitor of (Annona Muricata L.) Togrowthof Porphyromonas Gingivalis. Pharmacon. 2017;6(3):99–104.

30. Nazir MA. Prevalences of Periodontal Disease, Its Association with Systemic Disease and Prevention. Proc - Int Symp Inf Process ISIP 2008 Int Pacific Work Web Min Web-Based Appl WMWA 2008. 2008;1(2):360–3.

31. Silaban R, Hutapea V. Processing of Virgin Coconut Oil, VCO throughCombinationTechniqueFermentationand Enzimatis UsingPapaya. 2012;55–64.

32. Seong Lin T. The Effects of Virgin Coconut Oil on Fibroblasts and Myofibroblasts on Diabetic Wound Healing. Med Health. 2019;14(2):132–41.

33. Achmad H, Djais Al, Jannah M, Huldani, Putra AP. Antibacterial chitosan of milkfish scales (Chanos chanos) on bacteria porphyromonas gingivalis and agregatibacter actinomycetescommitans.

Systematic Review In Pharmacy. 2020;11(6):836-841.

34. Djais Al, Achmad H. Dewiayu D, Sukmana BI, Huldani. Effect of Combination Demeneralization Freeze Dentin Matrix (DFDDM) and moringa oleifera lam osteoprotegerin (OPG) and receptor activator of nuclear factor kappa bliganf (RANKL) as a marker of bone remodelling. Systematic Reviews in Pharmacy. 2020;11(6):771-779.

35. Achmad H, Djais, Syahrir S, Fitria A, Ramadhany YF. Impact Covid-19 in pediatric dentistry: A Literatur Review. International Journal Of Pharmaceutical Research. 2020. 12:830-840

36. Achmad H, Djais AJ, Petrenko EG, Laris V, Putra AP. 3-D printing as tool for applying biotechnologies in modern medicine. International Journal of Pharmaceutical Research.

2020;12(4):3454-3463SS

37. Achmad H, Djais Al, Syahrir, Fitria A, Ramadhany YF. A Literature us regarding the use of herbal medicines in pediatric dentistry. International Journal Of Pharmaceutical Research. 2020;12:881- 897