Garlic as a novel therapeutic agent for the management of pulp infections: a systematic review

In vitro studies have shown that garlic extracts are effective against microorganisms commonly associated with root canal infections, with the ability to penetrate bacterial biofilms and inhibit the growth of resistant strains. Building upon this preclinical evidence, the objective of the present systematic review was to identify, critically analyze, and synthesize the available clinical trials on the efficacy of garlic as a therapeutic agent in the management of pulp infections. The review was conducted following PRISMA guidelines and registered in PROSPERO, including clinical trials evaluating garlic-based treatments. A literature search was performed, studies were screened, data extracted, and the risk of bias was assessed using the Cochrane tool and the Newcastle-Ottawa Scale. Certainty of evidence was graded with the GRADE approach. Sixteen studies were included, of which 13 evaluated garlic-derived compounds as intracanal medicaments. Clinical success rates were generally high (≥ 90%), with outcomes comparable to formocresol and MTA, and at lower costs. Radiographic success ranged from 55% to 100%, with some studies showing superior results in reducing periapical signs. Microbiological analyses demonstrated a significant short-term reduction in bacterial load, with superior efficacy compared to conventional agents. Three additional studies investigated garlic-based irrigants, reporting moderate-to-high clinical success (around 75%). Overall, the included studies demonstrated a low risk of bias. The certainty of evidence was rated as moderate for randomized controlled trials and low for non-randomized trials. Low-to-moderate certainty evidence suggests garlic-derived formulations may improve clinical and radiographic outcomes when used as irrigants or intracanal medicaments in pulpotomy and pulpectomy procedures in endodontic practice. However, evidence remains limited, and well-designed, standardized clinical trials with long-term follow-up are needed to confirm their efficacy and safety.