Antifungal Efficacy of Pomegranate Peel Extract Against Candida albicans in Patients Wearing Removable Orthodontic Appliances in Tripoli, Libya

Abstract

Orthodontic treatment with removable appliances may increase Candida albicans colonization, a key opportunistic pathogen in the oral cavity. Herbal extracts, including pomegranate peel, exhibit promising antifungal properties and may offer natural therapeutic alternatives. This study aims to determine the association between removable orthodontic appliances and Candida albicans oral infections, and to evaluate the antifungal potential of pomegranate peel extract (PPE). This study was conducted in Tripoli, Libya (May 2023 – June 2025), enrolling 100 patients (50 orthodontic appliance users as the study group; 50 non-users as controls). Oral swabs were cultured on Sabouraud Dextrose Agar (SDA). Positive isolates were confirmed using the germ tube test and growth at 45°C. PPE was prepared by alcoholic extraction and tested via well-diffusion and microdilution methods. Antifungal susceptibility to fluconazole, nystatin, and miconazole (Daktarin) was assessed by disk diffusion. Culture positivity was 70% in the control group and 72% in the orthodontic group, with no statistically significant difference between groups (Chi-square test, p = 0.828). PPE inhibition zones ranged from 9 mm (12.5 mg/mL) to 22 mm (150 mg/mL); the MIC was 12.5 mg/mL. Fluconazole resistance was 84.5%, miconazole resistance 73.2%, and nystatin resistance only 12.7%. Removable orthodontic appliances may promote C. albicans colonization by altering the oral environment. PPE effectively inhibits yeast growth in vitro, suggesting potential as a complementary antifungal agent. High fluconazole resistance highlights the urgent need for alternative treatments in Libya.