The Earths beautiful creature – Honeybees produces honey that provides many uses and benefits for everyday life, but it’s not only the substance produced. The second most important component is the beeswax which forms the structure of honeycomb and is often confused with propolis, but these are not the same. Beeswax is the natural secretion from the wax gland and is used to construct the cell walls of the hive while propolis (bee glue) is a sticky resin of plant derivative and is used to assemble the hive; due to this it can be combined with beeswax but the best propolis is beeswax free.

Beeswax was originally the only natural wax in commercial use and has been a valuable substance ever since 14th century. The “father of medicine” Hippocrates, recommended the use of beeswax in treating purulent tonsillitis; although it was first used in medicine by the ancients in making salves and healing ointments, its subsequent use was restricted to making artificial flowers, wax figures, masks and candles. In tune with the demands of the modern society and to use natural resources as cure for many diseases it has regained its popularity in medical field. Propolis medicinal value is well documented in literature due to its antibacterial, antifungal, antiviral, antioxidant, and anti-inflammatory properties but the pharmacological properties pertaining to beeswax is still in debate.

The most commonly used derivative of beeswax is bone wax which is the refined formulation used as the primary method to control bone bleeding during most surgical procedures. At the present time, beeswax has many uses in industry, pharmacy and in medicine so an accurate knowledge of its production, composition and uses is important. Due to the paucity of literature regarding the use of beeswax in different clinical scenario, the above article is an attempt to highlight the uses and advances especially in oral and maxillofacial surgery.

Production

Beeswax is a natural wax produced by honey bees of the genus Apis mellifera and Apis cerana. They have life span of 35 days and wax production is during 10th-16th days of their life with the help of 4 pairs of wax producing gland. These glands convert the sugar consumed by them in the form of honey into wax which is extruded through small pores appearing as small flakes on the bees’ abdomen. The flakes are transparent and becomes white after being chewed and mixed with salivary secretions. These are then used by the bees as a construction material for their combs.

Manufacturing methods for beeswax

The quality of beeswax depends greatly on the production methods; which could be either melting or chemical extraction. Melting is the most frequently used procedure and could be carried out in the following ways: Hot water extraction using forced immersion, extraction with boiling water and wax press, combined steam and press extraction, steam extraction, centrifugal extraction. The chemical extraction by solvents is feasible only in a laboratory, where small scale wax production is needed. The most commonly used technique is hot water extraction using forced immersion. Here the honey combs are immersed in water for 4-5hrs and later washed to separate the water soluble impurities. The procedure is repeated atleast 2-3 times following which the combs are placed in an aluminum container with 20-30 lts water and boiled to melt the wax. This mixture is filtered out to another container where it is left to cool. As the wax is lighter than water, it rise to surface which could be easily separated out. When allowed to cool down wax solidify to form a block which could be easily transported.

Uses in surgery

On literature review the history of use of beeswax dates back to 1880 and various interesting uses have been mentioned in different parts of world. The uses of beeswax in the surgical field could be listed as follows:

1. As an augmentation material: The first documented use of beeswax was as soft tissue augmentation material where it was used as an injection to enhance macro facial esthetics, however was later discarded secondary to undesirable tissue reaction.
2. As an impression material: In the late 1945 when the light body elastomers or the newer imaging scanners were not yet in clinical use, mixture of beeswax with vaseline was the choice of intraoperative impression material to record the skull defect where cranioplasty with acrylic plates where performed. It was also used to reproduce the details of vomerine bone when obturator was used in the management of cleft lip and palate.
3. As hemostatic agent: Till date the most promising use of beeswax is as a local hemostatic agent in the form of bone wax, which was first described by Parker and Horsley in 1892. Like any living tissue, bone will bleed when cut or fractured, thus requiring hemostasis to ensure visibility by maintaining a fine balance between bleeding and clotting during surgery. The most effective and immediate way is by physically blocking the vascular channel and is known as tamponed. In this regard the widely used material is bone wax which is a mixture of beeswax. Since that time, bone wax has achieved widespread acceptance, because it is simple to use and effective in achieving hemostasis on hard tissue surfaces and the formulation has remained relatively unchanged consisting of refined beeswax (88%) and isopropylpalmitate (12%).
4. Treatment of Myiasis: Beeswax is also used in treating cases of myiasis of oral cavity where occlusion or suffocation approach is carried out as an adjuvant to surgical debridement. In this approach beeswax could be used to occlude the orifice forcing aerobic larvae to surface in search of air where they can be removed with the aid of forceps or tweezers.
5. As a coating material in sutures: Another use in the field of surgery is, beeswax as a coating material in non resorbable sutures eg: silk. Their specific use is mainly in braided or twisted sutures to facilitate handling properties, particularly reduction in tissue drag when passing through the needle tract and the ease of sliding knots down the suture during knotting.
6. Non adhesive dressing: Following skin grafting the most commonly used non-adhesive wound dressing is silk fibroin fabrics coated with biocompatible wax like beeswax. The addition of wax reduces the surface energy of the fiber, making it more hydrophobic thus it would loosely adhere to the hydrophilic wound surface ensuring easy removal with less trauma. It also has the advantage of turning the necrotic skin to yellow, leathery crust with good resistance to infection which enables the surgeon to excise the wound stage by stage where early massive excision not possible. It is also used in management of wound secondary to burns. In recent years efforts have been made to produce nanofibres with potential bioactive wellness properties by incorporating beeswax in the form of solution or micro emulsion and not merely as traditional coating materials.
7. Compression dressing for management of keloids: Its use in the management of keloids is also been reported in the literature, where a block of beeswax (2cm thick) is easily customized to the shape of keloid and then used as compression dressing over the silicone gel sheets.

Discussion

Readily available information about composition of beeswax was critically summarized in 1963 by Callow as a complex mixture of hydrocarbons (14%), monoesters (35%), diesters (14%), triesters (3%), Hydroxy monoester (4%), Hydroxy polyester (8%), oxides (12%) and exogenous substances(10%). Whatever beeswax is to be used for, it has to be melted, cleaned and turned to a solid wax block, where it could be stored or transported without any problems. Quality control of beeswax requires a great amount of specific knowledge and experience as the potential problem is the content of heat-resistant spores of Paenibacillus larvae. These are not destroyed by normal boiling of wax and thus requires heating under pressure (1400 hPa) at 120°C for 30 minutes to kill the spores. The increasing use of beeswax in medical field is due to its inertness and high plasticity at a relatively low temperature (32ºC) as well as its inherent antibacterial property. It has specific gravity of 0. 95 and melting point of 64. 39º C. Crude beeswax showed antibacterial activity against several bacterial strains invitro like Aspergillus Niger, Candida species, Salmonella enterica, Staphylococcus aureus, Pseudomonas aeruginosa and Escherichia coli. It should be noted that due to the presence of pro-vitamin A and other biologically active substances, it is able to stimulate tissue regeneration, which results in quick healing of the affected tissues. Even though Pogosyan et. al justified its use as tissue regeneration material, the use of beeswax in guided tissue regeneration remains unexplored. The anti-inflammatory, bactericidal and anti-oxidative features of beeswax has been well mentioned in the literature but there is definite lack of human studies supporting its use in guided tissue regeneration for repair of surgical defects. Thus further experimental studies are required to evaluate the efficacy of beeswax membrane in tissue regeneration. With further research technique it could open a new horizon for using beeswax in the field of surgery other than its traditional use as hemostatic agent which is well documented in the literature.

Conclusion

Beeswax based preparations have a wide range of applications in various specialties of dentistry including the surgery due to its antibacterial, antifungal, anti-inflammatory properties. Although it offers many benefits, one should remember that its use may bring in the risk of foreign body reaction. We would like to conclude it would be appropriate to conduct further studies on beehive products and in particular beeswax to investigate its merit and demerits in the surgical field.