Antioxidants are agents that save cells from the harmful effects of reactive oxygen species (ROS). Examples of ROS are singlet oxygen, superoxide, peroxyl, and hydroxyl radicals. These ruthless free radicals originate from endogenous stressors, resulting from natural by-products of cellular metabolism, or exogenous stressors such as UV light, pollutants, drugs, smoke, or radiation. As their name suggests, these reactive molecules provoke the deterioration of membranes, lipids, amino acids, and DNA. The damage to the DNA can lead to the breakdown of collagen, thus disrupting the proliferation stage in the wound healing process.
In the haemostasis stage at the beginning of the wound healing process, vasodilation takes place around the wounded tissue. However, overstimulation of vasodilation caused by inducible nitric oxide synthase (iNOS) may lead to the production of hydrogen peroxide and other ROS. These free radicals can generate oxidative stress and further worsen the condition of the wounded tissue. The accumulation of ROS will not only harm the wounded site but also spread it across other organs in the body. ROS can activate various humoral and cellular mediators to initiate the inflammation process at the distant organs.
Antioxidants act as a saviour to the structure of cells by neutralizing ROS and thus terminating the damaging chain reaction in the body. Antioxidants can be categorized into 2 types, namely, enzymatic and non-enzymatic antioxidants. Enzymatic antioxidants transform a free radical into a stable molecule that is less harmful to the body. These antioxidants can be further classified into several classes, which are ascorbate peroxidases, catalase, superoxide dismutase, glutathione peroxidase, glutathione reductase, and glutathione S-transferase. On the other hand, the non-enzymatic antioxidants block and cut the damaging chain reaction caused by ROS or even inhibit the formation of free radicals. Examples of these antioxidants are ascorbic acid, tocopherol, carotenoids, and phenolic compounds.
The major therapeutic action of honey in improving the wound healing process comes through its antioxidant activity since it can prevent the detrimental effects on the wounded site caused by oxidative stress. It can be postulated that the antioxidant effects of stingless bee honey can also be applied to the treatment of wounds since its antioxidant content is higher or similar to that of other types of honey. Research on the stingless bee (Meliponini tribe) in Australia indicated that the honey produced contains a higher level of flavonoids than the honey produced by A. mellifera. The total antioxidant activity in the Tetragonula carbonaria (stingless bee) honey was proven to be higher than that of the European floral honey, while its radical scavenging activity is equal to that of the European floral honey.
These findings are supported by another research study on the Melipona fasciculate (another stingless bee species), where the content of polyphenol in this stingless bee honey is the highest in comparison with other South American honey bees. In Malaysia, the researchers from MARDI have revealed that the major free phenolic acid in stingless bee honey consists of protocatechuic acid (PCA) and 4-hydroxyphenylacetic acid. PCA is a strong antioxidant that can improve cell proliferation in the wound healing process, whereas 4-hydroxyphenylacetic acid is able to scavenge the reactive oxygen and nitrogen species.
As a matter of fact, another product generated from stingless bees, such as cerumen, also has antioxidant properties. In an in vitro study using 5-lipoxygenase (5-LOX) cell-free assays, the polar extract of cerumen has shown the ability to suppress the catabolism of linoleic acid, thus displaying a potent antioxidant effect that can prevent lipid peroxidation and protect the integrity of the cell membranes. In addition, it has been shown that the ethanol extract of cerumen possesses antioxidant properties that reduce the number of ROS and protect human erythrocytes from lipid peroxidation in an antioxidant assay by using a human erythrocyte model. This action is attributed to phenolic compounds, which are important antioxidant components that inhibit haemolysis in erythrocytes. The high antioxidant content in stingless bee honey may provoke interest in the application of this honey in wound healing research.
Microorganisms exist inside all wounds but the majority of them do not infect the wound, and the wound will heal eventually. This situation happens when the host's immune system and the bioburden of the wound are in a state of equilibrium. Bioburden is a condition where an object is contaminated by a number of bacteria. Nevertheless, if the bioburden overcomes this balance, or there is impairment in the wound healing process, the bacteria will proliferate and occupy the host's tissues. The invasion of foreign bodies into a wound could hinder the healing process and may eventually cause the formation of a granuloma or an abscess. If no action is taken, another problem will arise later, where the leftover collagen produced during the prolonged wound healing process will build up keloid scars.
As previously mentioned, there are several microorganisms present in the cerumen during honey production. There is some conundrum whether this may impact the healing process when applying honey to the wound. These microorganisms cannot hinder the healing process since most of them have been identified as non-pathogenic which are from the Bacillus genus and actinomycete Streptomyces. In contrast, several notorious bacteria like Escherichia coli, Pseudomonas aeruginosa, Staphylococcus aureus, Clostridium, and Coliform species tend to disturb the healing process. As a consequence, a prolonged and abnormal inflammatory response will occur together with tissue damage and delayed healing. If this situation is prolonged, it may worsen and can lead to systemic illness. Therefore, an intervention should be introduced immediately after the injury as a precautionary measure. A nursing approach to wound healing focuses on preventing pathogenic colonization and eradicating these foreign invaders that are causing the wound healing process to remain at a stagnant phase.
The main point of antimicrobial or antibacterial applications is to prevent or confront infections, especially during the injury period. Stingless bee honey can be used as an antibacterial ingredient in pharmaceutical formulations since it possesses antimicrobial and antiseptic properties. The antimicrobial activity of stingless bee honey was validated by using the Kirby-Bauer antibiotic test, the agar dilution test, broth microdilution, and time-kill viability assays. This study was supported by researchers from Brazil where they found that stingless bee honey has the ability to inhibit the growth of gram-positive and gram-negative bacteria.
A unique feature of stingless bee honey is that it is stored in cerumen pots made of wax and propolis. Choudhari et al. found that propolis from India has a compelling antimicrobial property. Similarly, Campos et al. also discovered that propolis samples in Brazil contain broad antimicrobial properties. Therefore, the quality of the honey stored in the propolis-infused cells is influenced by its beneficial content.
The antibacterial effect of honey can be divided into peroxide and non-peroxide components. The peroxide component is based on the activity of hydrogen peroxide. Hydrogen peroxide is regulated by 2 important enzymes in honey, namely, glucose oxidase and catalase. Glucose oxidase induces the production of hydrogen peroxide, while catalase will destroy the hydrogen peroxide in order to preserve the nutritional content of the honey. Hydrogen peroxide will enhance the production of cytokines for the inflammatory response to kill the bacteria. The non-peroxide components are based on phytochemicals, high sugar content, and the acidity of the honey. The phytochemical components in honey that contribute to the antibacterial effects are flavonoids, phenolic substances, and antibacterial peptides. These components may act by directly inhibiting phagocytosis, thus preventing the superoxide free radicals from damaging the tissues. The last non-peroxide component is the acidity in the honey caused by organic acids. These acids, which make up 0.57% of the honey itself, will suppress the majority of the microorganisms that grow in a pH of between 7.2 and 7.4.
In stingless bee honey, the antibacterial effect is influenced by non-peroxide activity. It is uncommon to observe non-peroxide activity in A. mellifera honeys, but Temaru et al. have demonstrated strong non-peroxide activity in a variety of samples of stingless bee honey across the world. An entomological study by Stow et al. has indicated that cuticular antimicrobial compounds that have been secreted from stingless bee honey are responsible for preventing microbial growth. From this finding, Irish et al. have postulated that the non-peroxide activity of stingless bee honey has a connection with the anatomical structure itself of the stingless bee. The non-peroxide activity has a more significant and substantial mechanism in antimicrobial action. Since there is a limitation of its counterpart; the peroxide activity is limited by the presence of catalase in the human body. Therefore, with these coveted antibacterial properties, the application of stingless bee honey on the wounded area may decrease microbial infection and thus rapidly initiate the healing process.
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In conclusion, it is important to take a serious note concerning wound care and healing agents due to the nature of the wound healing process, which is highly complex and highly exposed to external infection. Phytochemical and pharmacological evidence has supported the ethnopharmacological use of stingless bee honey in wound care. All of these beneficial effects could enhance the stingless bee honey profile as a wound healing agent. Historically, the application of honey to the wound has been used since ancient times; therefore, it is essential to understand its pharmacological action towards the physiology of the wounded skin in order to optimize the healing rate. Stingless bee honey has a lot of similarities with other honeys in terms of its bioactive components, but the efficacy of the components has yet to be discovered. As a result, more systematic research is needed to provide comprehensive scientific evidence for its use as well as to clarify any doubt and false acclaim. The potent biological activities of stingless bee honey may create a new therapeutic choice from the current honey and represent an interesting advance in the search for promising applications in the pharmaceutical industry for the wound healing area.