OSTEOGENIC POTENTIAL OF MORINGA OLEIFERA – A SYSTEMATIC REVIEW OF IN-VIVO STUDIES

OSTEOGENIC POTENTIAL OF MORINGA OLEIFERA – A SYSTEMATIC REVIEW OF IN-VIVO STUDIES

Reetika Gaddale * and Ramesh Chowdhary

Department of Periodontology, Sri Siddhartha Dental College, S. S. A. H. E. University, Tumkur, Karnataka, India.

ABSTRACT: Background: Alveolar bone defects are common in dentistry. Bone tissue repair involves a complex inflammatory process, regulated by osteoprogenitor cells from the periosteum and endosteum, which are vital for new bone matrix formation. Recently, plant extracts have gained attention as potential treatments for bone lesions. Moringa oleifera exhibits various medicinal properties, largely due to its flavonoid content, which supports osteoblastic proliferation. These compounds enhance osteogenic differentiation and aid in bone defect healing. This review aims to assess the effectiveness of Moringa oleifera in promoting bone regeneration in in-vivo models. Methodology: A comprehensive electronic literature search was conducted using Medline/PubMed database based on PICO analysis. From an initial pool of 40 papers, 6 in-vivo studies using Moringa oleifera-based biomaterials met the inclusion criteria. Results: After removing duplicates and irrelevant abstracts, 9 studies remained. Four were excluded for not meeting inclusion criteria. One additional paper was identified through hand searching, totaling 6 included studies. Animal models used were Cavia cobaya, rats, and rabbits. Moringa oleifera was applied in various forms: leaf extract combined with DFDBBX, beta-tricalcium phosphate, marine collagen, hydrogel, and PRF. Bone regeneration was primarily assessed using micro CT and histological analysis. Conclusion: Moringa oleifera promotes bone repair by enhancing osteogenesis, increasing calcification, and supporting bone callus formation and mineralization. These effects are likely due to its anti-inflammatory and antioxidant properties.

Keywords: Bone defects, Bone fill, Bone regeneration, In-vivo, Moringa oleifera

INTRODUCTION: Bone remodelling is a highly coordinated process involving a series of cellular events, including inflammation, cell proliferation, and matrix remodelling, regulated by osteogenesis and angiogenesis ¹. The skeletal system possesses a remarkable ability to regenerate, allowing it to maintain both structure and function. However, certain clinical conditions require accelerated bone formation to optimize healing outcomes ².

To address this, researchers have been investigating the inflammatory mechanisms that govern bone repair, aiming to identify novel therapeutic targets for treating bone defects ^{3, 4}. In this regard, natural compounds, biomaterials, and their derivatives have emerged as promising alternatives, offering potential benefits such as reduced side effects, lower costs, and enhanced healing efficiency ⁵.

Plants have long been a vital source of nutraceuticals, offering health benefits, disease prevention, and therapeutic applications, while also playing a significant role in modern pharmaceutical research. Approximately 75% of the global population ⁶ relies on plant-derived medicines, which remain the primary treatment approach in many developing countries ⁷.

Research indicates that certain bioactive compounds extracted from natural sources exhibit potent anti-inflammatory, antioxidant, and regenerative properties, supporting their effectiveness in treating various diseases ⁸. However, the precise mechanisms by which these natural compounds influence inflammation and bone healing remain inadequately understood. Existing evidence is limited, fragmented, and based on isolated studies, leading to inconsistencies in the literature. Despite this uncertainty, it is believed that plant extracts contribute to bone repair by enhancing antioxidant defenses, reducing tissue inflammation, promoting vascularization, and stimulating the proliferative activity of bone cells.

Moringa oleifera is one of the most extensively cultivated species within the Moringaceae family. It originates from regions of Southeast Asia, Africa, and the Americas. In these areas, its leaves, flowers, and young pods are commonly consumed as vegetables ⁹. The plant is renowned for its rich nutritional and phytochemical composition, serving as an excellent source of proteins, vitamins, and bioactive compounds. It contains antioxidants, flavonoids, saponins, alkaloids, tannins, and phenolic compounds, along with essential minerals such as calcium, phosphorus, magnesium, potassium, sodium, sulphur, zinc, copper, manganese, iron, and selenium ¹⁰. Every part of Moringa oleifera possesses medicinal properties, demonstrating a wide range of pharmacological activities, including antihyperglycemic, antidyslipidemic, antioxidant, antihypertensive, immunomodulatory, chemoprotective, radio-protective, diuretic, anti-inflammatory, antipyretic, antiepileptic, antitumor, antiulcer, antispasmodic, antibacterial, and antifungal effects ¹¹. This extensive therapeutic potential is likely attributed to its unique composition of bioactive compounds, such as rhamnosyloxy benzyl isothiocyanate and its derivatives, niaziminins, niazinins, β-sitosterol, niacin, phenolic acids, glucosinolates, flavonoids, gallic acid, coumarin, and caffeic acid.

Notably, the leaves and other plant parts contain a distinctive combination of zeatin, quercetin, β-sitosterol, caffeoylquinic acid, and kaempferol ^{12, 13}. Among these, β-sitosterol and quercetin have been shown to promote cell proliferation and regeneration ¹⁴. Therefore, this systematic review aims to evaluate the osteogenic potential of Moringa oleifera in facilitating bone regeneration.

MATERIAL AND METHODS: The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines ¹⁵ offered a precise process that was followed in selecting the systematic review's methods and inclusion criteria Fig. 1.

FIG. 1: PRISMA FLOWCHART

Research Question: Is Moringa oleifera effective in promoting bone regeneration?

Population, Intervention, Comparison and Outcome (PICO) Analysis: The PICO analysis ¹⁶ was used as follows: population/problem (P) - osseous defects OR bone defects OR intrabony defects in animal models, intervention (I) – Moringa oleifera, comparison (C) – control OR vacant OR unfilled bone defects, and outcome (O) - bone regeneration OR bone fill.

Inclusion and Exclusion Criteria: This review included only research studies, excluding conference papers, abstracts, pilot studies, reviews, communications, letters to the editor, and editorials. Additionally, studies published in languages other than English were not considered. Regarding study relevance, only in-vivo research involving Moringa oleifera was selected, without restrictions on animal species or bone defect modelling techniques. Any Moringa oleifera-based biomaterial, such as hydrogels, scaffolds, etc were included. There were no limitations on the types of biomaterials or chemical compounds combined with Moringa oleifera.

Search Strategy & Selection of Studies: In February 2025, an extensive electronic literature review was conducted on Medline/PubMed database to search for the article published in English language, without any limitations on the year of search using the terms “bone defects”, “Moringa oleifera”, “bone fill”, “bone regeneration”. Additionally, a manual search was conducted to find other suitable studies by examining the references of the included studies and other published reviews.

The selection process began with the removal of duplicate articles, followed by screening the titles and abstracts of the remaining studies to determine their eligibility. After applying the inclusion and exclusion criteria, full-text assessments were conducted on the qualifying articles. Reviewer RG carried out the article selection process based on the predefined criteria, while reviewer RC re-evaluated the selection strategy and provided input in cases of uncertainty regarding article inclusion or exclusion. Any disagreements were resolved through a consensus-based approach, and the level of agreement among the reviewers was measured using Kappa statistics.

Data Extraction: Data was extracted by RG from each study under the following headings - author, year, study design, aim, methodology, results and conclusion.

Risk of Bias (ROB) Assessment: For animal studies, the SYRCLE’s RoB tool an adaptation of the Cochrane ROB tool was utilized to address biases specific to animal intervention research ¹⁷. This tool assessed multiple domains, including selection bias (covering sequence generation, baseline characteristics, and allocation concealment), performance bias (evaluating random housing and blinding methods), detection bias (considering randomization and blinding in outcome assessment), attrition bias (examining incomplete outcome data), reporting bias (analyzing selective outcome reporting), and other potential sources of bias. To facilitate this evaluation, signal questions were used, with responses categorized as “Yes” for a low risk of bias, “No” for a high risk of bias, and “Unclear” when insufficient information was available to determine the bias risk accurately.

RESULTS:

Literature Search: Initially, the literature search resulted in 40 papers. Thirty-eight papers remained after excluding duplicate articles, out of which 29 papers were further excluded following the screening the abstracts, resulting in 9 studies for retrieval. Four studies did not fulfil the inclusion criteria, hence were excluded Fig. 1. The hand search resulted in 1 additional paper, and finally, 6 articles were included in this review. The reviewers had a high level of agreement (k= 0.867).

Study Description: The characteristics of the included studies are tabulated in Table 1. The animals used in in-vivo studies included Cavia cobaya, ^{18, 19} rats ^{20, 21} and rabbits ^{22, 23}. The bone defect models in Cavia cobaya included mandibular incisor sockets ^{18, 19}, in rats it was the femoral bone ^{20, 21}, in rabbits one study used buccal bone defects ²² and other study used mandibular edentulous area ²³ as bone defect model. The various forms in which MO was used in bone defects were, Moringa leaf extract and DFDBBX, ^{18, 19}combination of MO and marine collagen,^{20, 21} moringa hydrogel and PRF, ²² MO plus beta tricalcium phosphate ²³. Assessment of bone regeneration in almost all studies was done by microCT and histological analysis.

TABLE 1: CHARACTERISTICS OF INCLUDED STUDIES

Quality Assessment: The risk of bias (RoB) assessment for in-vivo studies was performed using SYRCLE’s RoB tool, as illustrated in Fig. 2. The analysis revealed a low RoB in the selection bias domain. Similarly, the reporting bias domain showed a low RoB, attributed to comprehensive documentation of both primary and secondary outcomes, as well as well-structured methodology and results sections across all studies. However, in other domains, such as random housing and blinding, more than 70% of the studies had an unclear RoB. This was mainly due to insufficient reporting rather than a lack of methodological rigor in housing conditions or outcome assessment timing.

FIG. 2: RESULT OF SYRCLE'S ROB ASSESSMENT

DISCUSSION: In this systematic review we aimed to evaluate the efficacy of Moringa oleifera (MO) extracts and their derivatives on bone repair in animal models. Despite the significant variability among the included studies, the overall findings suggest that MO extracts were effective in promoting bone healing. Treatment with MO extract led to the release of markers and anti-inflammatory mediators, accelerating the bone repair process. Additionally, histopathological and radiological assessments revealed key indicators of bone remodeling, such as new bone formation, callus development, increased cell proliferation, and enhanced osteogenesis. These findings suggest that certain bioactive compounds within the extracts may stimulate the proliferation of specific cell types, likely due to their interactions with cellular components involved in the healing process.

The studies included in this review utilized rats, rabbits, and Cavia cobaya as experimental models. While the results from these animal models cannot be directly extrapolated to humans, ²⁴ they offer valuable insights into the biology and pathophysiology of bone lesions and are essential for research ²⁵. The main advantage of using these animals lies in the reduced costs, as more animals can be housed in a smaller space, and their shorter reproductive cycles. These factors make it possible to generate a sufficient number of animals for large study groups in a relatively short period, facilitating robust statistical analyses ²⁶. Other parameters that showed significant variation included the type and size of bone defects, as well as the treatment duration. Radiological assessments were useful for evaluating bone fill, while immunohistochemical and histopathological analyses were crucial for interpreting and confirming the cellular effects of phytotherapeutic compounds in tissue repair ²⁷. These analyses helped identify the role of osteogenic cells in bone callus formation, cell organization, and the release of immunomarkers ^{28, 29}. The synthesis of proinflammatory mediators, observed in both spongy and compact bone regions through immunological and histopathological analyses, was higher in the MO treatment groups compared to the control groups, indicating the effectiveness of the extracts in promoting bone repair. This suggests that certain components of the extract, or their synergistic effects, may enhance the synthesis of specific mediators and stimulate the proliferation of certain cell types, thereby accelerating bone matrix synthesis and bone callus formation ³⁰.

Moringa leaf extract is abundant in flavonoids, saponins, alkaloids, and tannins. Flavonoids, particularly kaempferol, quercetin, and others, are effective in managing various inflammatory conditions ³¹ due to their ability to inhibit the cyclooxygenase-2 (COX-2) enzyme, which plays a role in producing inflammatory mediators derived from arachidonic acid. These flavonoids also block the release of histamine from mast cells and basophils, exerting anti-inflammatory effects. As a result, the activity of COX-2 reduces the production of pro-inflammatory mediators such as IL-1, IL-6, and TNF-α ³². Kaempferol and quercetin also directly inhibit TNF-α activity and RANKL expression ³³. Both flavonoids are capable of binding to atoms or acting as scavengers for free radicals, preventing the excessive formation of reactive oxygen species (ROS). Additionally, quercetin can inhibit osteoclast differentiation and activation, as well as induce osteoclast apoptosis ^{34, 35}.

Moringa leaf extract possesses indirect osteoinductive properties due to its unique composition. A study by Zhang et al. demonstrated that flavonoids can stimulate osteoblast proliferation and differentiation ³⁶. This finding is further supported by Patel's research, which showed that flavonoid compounds from Moringa leaf extract aid in osteoblast differentiation, promoting bone formation ³⁷. Additionally, saponins found in Moringa leaf extract enhance osteogenic activity, encouraging the proliferation and differentiation of osteoblasts ³⁸. Tannins, present in the extract, have been shown to inhibit osteoclast differentiation, thus supporting the formation of new bone ³³. Consequently, studies that combined Moringa extract with bone substitutes such as DFDBBX ^{18, 19} and β-TCP ²³ reported improved bone regeneration compared to controls, owing to the osteoinductive properties of Moringa and the osteoconductive properties of the bone substitutes, which act as scaffolds.

M.I. Khan et al.³⁹ conducted a study to elucidate the dose dependent effects of Moringa oleifera leaf extract on the growth of the human osteoblast-like osteosarcoma SaOS-2 cell line and primary osteoblast cells. β-sitosterol was found to be biologically active components against G-protein coupled receptors (GPCR) and acting as ion channel modulator, nuclear receptor, protease inhibitor and enzyme inhibitor. Quercetin and kaempferol, on the other hand, showed active kinase and other enzyme inhibitors and act as active components against nuclear receptor. Authors concluded that MO worked as anti-osteosarcoma agent at high concentration via modulating ROS, chromatin condensation, and cell cycle arrest. Low concentrations, on the other hand, stimulated proliferation, differentiation, and mineralization and induced expression of BMP2 and Runx2 (runt-related transcription factor 2) osteogenic genes. Thus, hermetic like biphasic concentration-dependent response of MO leaves might be crucial element in bone pathogenesis. Moreover, Moringa leaf extract contains various phytochemicals, particularly phytoestrogens, which have beneficial effects on bone health. Phytoestrogens are plant-derived compounds that mimic the bioactivity of estrogen due to their structural similarities with estradiol (17-beta-estradiol), one of the naturally occurring forms of estrogen in the body. These phytoestrogens are primarily classified as flavonoids within the isoflavonoid group. They positively influence bone health by stimulating osteoblast activity through estrogen-mediated mechanisms ^{40, 41}.

P.R. Pachimalla et al.⁴² formulated a hydrophilic gel containing Acemannan and Moringa oleifera to be used in conjunction with dental implant placement, aiming to create a hydrophilic surface for the implant, enhance blood-implant contact, and improve bone-implant integration in rabbits. The results demonstrated significant new bone formation in the tibia, suggesting that the hydrogel's components promoted bone growth by increasing osteoblastic activity. As noted in studies by Das et al.⁴³ and Patel et al.³⁷ there were no signs of degenerative changes, necrosis, fibrosis, or inflammation at the site of the new bone-implant interface.

One limitation of this review is the potential publication bias within the included articles. Several experimental aspects were overlooked, such as the absence of randomization, which highlights the need for improved experimental designs and stricter adherence to guidelines in reporting animal studies to ensure reliable scientific evidence. Furthermore, the incomplete phytochemical characterization of Moringa oleifera extracts makes it challenging to pinpoint the specific compounds responsible for the observed positive effects. Lastly, the methodologies and evaluation parameters across the studies were highly varied, with different measures reported in each study, contributing to a lack of consistency.

CONCLUSION:

The following conclusions can be drawn:

1. Moringa extracts promote bone repair by enhancing osteogenesis, increasing calcification, and facilitating the formation and mineralization of bone callus, there by accelerating the process of new bone formation.
2. These effects are likely linked to the anti-inflammatory and antioxidant properties of the extracts.
3. However, more detailed methodological descriptions are necessary to facilitate better comparison across studies and ensure the reproducibility of future research.

ACKNOWLEDGMENT: None

CONFLICT OF INTEREST: No conflict of interest.

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    Gaddale R and Chowdhary R: Osteogenic potential of Moringa oleifera – a systematic review of in-vivo studies. Int J Pharm Sci & Res 2026; 17(2): 417-26. doi: 10.13040/IJPSR.0975-8232.17(2).417-26.

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