|Year : 2017 | Volume
| Issue : 1 | Page : 37-40
Effect of herbal mouthwash on periodontal parameters and P. gingivalis
Sonam Mufti1, Sarvagna Dadawala2, Phoram Patel2, Monali Shah2, Deepak Dave2
1 Vaidik Dental College and Research Center, Daman, Daman and Diu, India
2 Department of Periodontology, K. M. Shah Dental College and Hospital, Sumandeep Vidyapeeth, Pipariya, Vadodara, Gujarat, India
|Date of Web Publication||6-Feb-2017|
105, Shalibhadra Complex, Near L.I.C. Quarters, Nanpura, Timaliyawad, Surat - 395 001, Gujarat
Source of Support: None, Conflict of Interest: None
Introduction: Inadequate control of dental plaque is one of the primary causative factors in the development of gingivitis and periodontal disease progression. Numerous agents have been available to reduce this plaque. Studies have shown the effects of chlorhexidine (CHX) and herbal mouthwash (HM) individually, but limited evidence has compared the efficacy of both clinically and microbiologically. Hence, this study evaluated the efficacy of HM and CHX on Porphyromonas gingivalis along with that of clinical parameters. Materials and Methods: This study was a randomised controlled double-blinded study. Thirty participants were divided into two groups (15 test and 15 controls). Each participant had undergone scaling and root planing and was then given either of the mouthwashes. Oral hygiene index-simplified, plaque index, gingival index and bleeding on probing were recorded. Subgingival plaque samples were taken to evaluate P. gingivalis by polymerised chain reaction. Results: HM showed significant results, and when antimicrobial efficacy was combined, clinically no statistical significance was seen compared to CHX. Participants' perception was also similar for both mouthwashes. Conclusion: HM was found equally effective against periopathogens and well accepted by the participants.
Keywords: Chlorhexidine, herbal mouthwash, Porphyromonas gingivalis
|How to cite this article:|
Mufti S, Dadawala S, Patel P, Shah M, Dave D. Effect of herbal mouthwash on periodontal parameters and P. gingivalis. Adv Hum Biol 2017;7:37-40
|How to cite this URL:|
Mufti S, Dadawala S, Patel P, Shah M, Dave D. Effect of herbal mouthwash on periodontal parameters and P. gingivalis. Adv Hum Biol [serial online] 2017 [cited 2019 Nov 15];7:37-40. Available from: http://www.aihbonline.com/text.asp?2017/7/1/37/199529
| Introduction|| |
The products extracted from plants are widely accepted in various medical as well as dental specialties for its safety as well as efficacy. Various herbal ingredients such as Pilu (Salvadora persica), Bibhitaka (Terminalia bellerica), Nagavalli (Piper betle), Gandhapura taila (Gaultheria fragrantissima), Ela (Elettaria cardamomum), Peppermint satva (Mentha spp.) and Yavani satva (Trachyspermum ammi) are used. Tree twig, known as Meswak, is a popular teeth-cleaning agent, which prevents tooth decay and eliminates toothache and bad breath. The herbal mouthwash (HM) contains all these ayurvedic products needed to be evaluated for its antiplaque efficacy, antigingivitis effect and antimicrobial action, especially on periodontal pathogens.
Dental Plaque is a specific but highly variable structural entity resulting from sequential colonization and growth of microorganisms on the surface of teeth and restorations which consist of microorganisms of various strains and species which are embedded in extracellular matrix. It is composed of bacterial metabolic products and substance from serum, saliva and blood. (WHO – 1978). Its inadequate control is one of the primary causative factors in the development of gingivitis and periodontal disease progression. This led to the concept that strict plaque control is a prerequisite for a stable and healthy periodontal condition.
Specific plaque hypothesis states that only certain plaque is pathogenic, and its pathogenicity depends on the presence or increase in specific microorganisms. This concept predicts that plaque harbouring specific bacterial pathogens results in periodontal disease because these organisms produce substances that mediate the destruction of host tissues. Porphyromonas gingivalis is the most aggressive periodontal pathogen. Studies have shown that P. gingivalis occurs with greater frequency and at higher levels at sites which appear to be disease active., While mechanical methods of plaque removal are considered the standard for individually applied oral disease preventive practices, the high prevalence of gingival disease has prompted research into and development of adjunctive methods for controlling oral biofilms.
Hence, a large number of commercial plaque control agents are available which can qualitatively and quantitatively affect the plaque formation along with the inhibition of P. gingivalis. Chlorhexidine (CHX) 0.2% as well as 0.12% was found most effective as a chemical plaque control agent  but has side effects such as brown staining, mucositis, parotid gland swelling and erosion.
Numerous studies have been done showing the effects of CHX and HM individually, but a very limited evidence has compared the efficacy of both clinically and microbiologically. Hence, this study evaluated the efficacy of CHX and HM on P. gingivalis along with that of periodontal parameters.
| Materials and Methods|| |
It was a randomised controlled double-blinded study started after obtaining approval from the Ethics Committee of Sumandeep Vidyapeeth University. The enrolment of the participants was carried out in the Department of Periodontics, K.M. Shah Dental College and Hospital and they were recruited from the above-mentioned source. A minimum sample size required for the study was 30 participants and they were divided into two groups (15 tests and 15 controls) who fulfilled the inclusion and exclusion criteria.
Participants aged more than 18 years who were systemically healthy, had more than 20 evaluable teeth of probing depth more than 5 mm and with the presence of bleeding on probing (BOP) in at least 30% of the sites were included in the study. Participants allergic to the active ingredients in any of the mouthwashes were excluded from the study. Furthermore, participants who habitually use tobacco, pregnant or lactating mothers, participants with orthodontic appliance, oral lesions and participants on any antibiotic in the past 3 months were also excluded from the study.
Oral hygiene index-simplified (OHI-S) (Green & Vermilion 1964), plaque index (PI) (Silness and Loe 1964), gingival index (GI) (Loe and Silness 1963) and BOP were recorded at baseline and after 15 days for both the groups regarding oral hygiene and periodontal status.
The sites were isolated with a sterile cotton swab; a sterile area-specific curette was introduced into the periodontal pocket, and a subgingival plaque sample was obtained and transferred into a sterile vial containing distilled water and sent for the detection of P. gingivalis using real-time polymerase chain reaction (PCR). Sample collections by real-time PCR analyses were performed at baseline and at 15th day re-evaluation. Microbiologic assays, primers and reaction templates were performed to measure the absolute quantification of P. gingivalis.
Randomisation technique and blinding
After meeting the inclusion and exclusion criteria, the participants were assigned by a lottery method in any of the two groups. Fifteen chits of Group A and 15 chits of Group B were kept in a box. Participants were asked to pick any one of the chits and received either Group A or Group B mouthwash. Co-investigator 2 had removed all labels of mouthwash bottles and replaced HM with A and CHX with B, thus the participants were blinded. Co-investigator 2 also dispensed the mouthwash after the participant picked the chit. Co-investigator 1 maintained the register of randomisation. Primary investigator who has recorded the clinical data as well as microbial sampling was also kept blind from the allotment. Group A as HM and group B as CHX were revealed only after statistical analysis.
Clinical periodontal procedure
All clinical as well as the microbial recordings were performed immediately before the scaling and root planing procedures (baseline). Plaque samples were obtained with the help of sterile Gracey curettes. The collected plaque samples were sent for PCR for qualitative analysis of P. gingivalis. Thorough scaling and root planing were done for all the participants and they were given either Group A or Group B mouthwash according to their random allotment. All the participants were then given a questionnaire to evaluate their attitudes with regard to the product used. All the participants were given similar tooth brush, tooth paste and brushing technique and instructed to rinse their mouth with the respective mouthwashes given to them for two times daily in the follow-up period. The recordings were again taken after 15 days.
| Results|| |
Mean of all parameters with interquartile range was derived and the intragroup analysis was done by Wilcoxon's test and intergroup analysis done by Mann–Whitney U-test.
The difference between the clinical parameters from baseline till follow-up for CHX and HM groups has been displayed in [Table 1]. The clinical parameters from baseline till follow-up were significantly reduced in the CHX group with respect to OHI-S (P = 0.006), GI (P = 0.006) and BOP (P = 0.001). PI did not show any statistical significant difference (P = 0.064). In the HM group, all the clinical parameters showed significant reductions from baseline till follow-up in relation to OHI-S (P = 0.001), PI (P = 0.012), GI (P = 0.053) and BOP (P = 0.003).
|Table 1: Difference between the clinical parameters from baseline till follow-up for chlorhexidine and herbal mouthwash groups|
Click here to view
When CHX group was compared with HM group, significant differences were seen with respect to all the clinical parameters except for BOP.
The difference between the microbiological parameters from baseline till follow-up for CHX and HM groups is displayed in [Table 2]. Once scaling and root planing were completed and mouthwash was given, the levels of P. gingivalis were found to be absent in both the groups showing significant reductions in the microbial levels with the use of mouthwashes.
|Table 2: Difference between the microbiological parameters from baseline till follow-up for chlorhexidine and herbal mouthwash groups|
Click here to view
Along with the clinical parameters, patients' perception towards using mouthwash was also evaluated by asking certain questions. With respect to the taste of the product, both the mouthwashes had good taste. CHX mouthrinse remained for a longer period of time in the mouth after rinsing compared to HM mouthrinse. The taste of the food and drinks was not affected by any mouthwash, and the plaque reduction was good with both the mouthwashes.
| Discussion|| |
Bacterial plaque has been known to be the prime etiologic factor behind chronic gingivitis and periodontal disease. Despite one's best efforts, mechanical aids may fail to adequately remove plaque biofilm or reduce the bacteria below the patient's threshold for disease. The ability of an oral rinse to be retained in the oral cavity and maintain potency over an extended length of time has been debated. Lang stated that the substantivity of an antimicrobial agent needs sufficient contact time with a microorganism to inhibit or kill it. CHX, with a substantivity of 8–12 h, is considered to be highly effective; whereas, the substantivity of the HM is unknown. Since the clinical parameters were not sufficient to establish any difference in the efficacy of the agents, it was decided to correspondingly evaluate their effects on the plaque microorganisms. This study aimed to determine the comparative effects of CHX and HM on clinical parameters and levels of P. gingivalis using PCR method.
The mean age of participants showed no significant difference between both the groups. With respect to the clinical parameters, both the groups showed significant and similar results.
The OHI-S index showed significant reduction in plaque and calculus scores after the treatment in CHX (P = 0.006) and in the HM groups (P = 0.001). Similarly for GI, a statistically significant reduction with P = 0.006 was seen in the CHX group and in the HM group with P = 0.01. These results were similar to a study by Southern et al. in 2006 which showed reduction in GI only in the CHX group. CHX demonstrated a 31% reduction in the proportion of GI scores in the CHX group whereas no significant difference was seen in the HM group. The PI in this study showed no significant difference in the CHX group (P = 0.064) whereas it was significantly reduced in the HM group (P = 0.01). A study done by Shetty et al. showed no significant difference between the PI scores between both the groups.
The bleeding scores in this study showed a significant reduction from baseline till follow-up in both the groups with P = 0.001 and P = 0.003 in the CHX and HM groups, respectively. There was no significant difference seen between both the groups with P = 0.141. These results were similar to the results of a study done by Anauate-Netto which showed efficacy of Propolis mouthwash only on papillary bleeding scores. It was found to be significant compared to that in the CHX group.
The levels of P. gingivalis were evaluated using the PCR qualitative method. P. gingivalis was present in almost 80% of the participants in both the groups before commencing any treatment. Once scaling and root planing were completed and mouthwash was given, the levels of P. gingivalis were found to be absent in both the groups showing significant reductions in the microbial levels with the use of mouthwashes. These results were similar with many other studies which had evaluated all the 40 strains of microorganisms using different microbial test techniques. A study done by Haffajee investigated CHX, herbal and essential oil mouthrinses' antimicrobial effectiveness against predominant oral bacteria, as determined by the minimum inhibitory concentration  (MIC). The results showed that the herbal mouthrinse inhibited the growth of most of the forty test species. Compared with the essential oil mouthrinse, the herbal mouthrinse exhibited significantly lower MICs for Actinomyces species, periodontal pathogens Eubacterium nodatum, Tannerella forsythia and Prevotella species, as well as the cariogenic pathogen Streptococcus mutans. The CHX gluconate rinse had the lowest MIC compared with the essential oil rinse and the herbal rinse for all the test species examined.
Similarly, a study by Duss et al. in 2010 suggested that neither 0.05% CHX/herbal extract nor 0.1% CHX mouthrinse group showed any difference in the change of bacterial counts for any species found between baseline and week 12. Another study done by Malhotra et al. in 2011 compared HM with CHX and found that HM was considered to be more effective inhibitor, though less effective than CHX, it can serve as a good alternative. In the questionnaire, with regard to the participants, no significant difference was seen between the two groups. However, CHX was found to remain in the mouth for a longer period of time compared to herbal rinse.
The result of this study shows improvement in oral hygiene instructions, PI and GI significantly compared to CHX group. P value for PI is 0.001, GI is 0.002 and OHI is 0.004. The result of this study is in accordance with that of Nadkerny et al. and Mali et al.
The clinical and microbiologic effects of both the mouthwashes were comparable. However, they leave only one area where the comparison between the two could be possibly relevant. It has been reported that long-term use of CHX is limited by staining of teeth and taste alteration. However, no such effect has been reported with herbal extracts. CHX's superior anti-plaque effect has been mainly attributed to its unique property of substantivity. The proposed mechanism of HM is due to its synergistic action of its potent herbs by virtue of their components which individually exert their antimicrobial activities. Whether substantivity exists or not could not be ascertained in this study.
A few limitations were obvious such as short duration, small sample size and limited microbial assessment. In addition, among the various side effects of CHX, only unpleasant taste was assessed in this study whereas other effects such as staining which is a rather long-term phenomenon could not be assessed due to short duration of the study. Further research needs to focus mainly on these areas and on substantivity of HMs.
| Conclusion|| |
Evidence in dental literature support and recognize chlorhexidine as gold standard against which other antiplaque agents are measured. But the long term use of chlorhexidine is limited by its side effects. Herbal products though negate these effects and can be used safely for a longer time period, still need to establish the property of substantivity in order to reach the gold standard of chlorhexidine. Hence, this trial highlights that herbal mouthwash is as efficient an antiplaque agent as CHX. It is significantly useful in reducing plaque accumulation and gingival inflammation, thereby preventing periodontal disease in the studied patients. It is also cost effective, easily available, and well tolerated with no reported side effects as compared to the gold standard, CHX. Thus it could be safely concluded that herbal mouthrinses can be used as adjuncts in periodontal therapy, however further long term research on a larger population is recommended.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Marsh PD. Dental plaque as a biofilm and a microbial community – Implications for health and disease. BMC Oral Health 2006;6 Suppl 1:S14.
Melvin WL, Assad DA, Miller GA, Gher ME, Simonson L, York AK. Comparison of DNA probe and ELISA microbial analysis methods and their association with adult periodontitis. J Periodontol 1994;65:576-82.
Preus HR, Anerud A, Boysen H, Dunford RG, Zambon JJ, Löe H. The natural history of periodontal disease. The correlation of selected microbiological parameters with disease severity in Sri Lankan tea workers. J Clin Periodontol 1995;22:674-8.
Pizzo G, La Cara M, Licata ME, Pizzo I, D'Angelo M. The effects of an essential oil and an amine fluoride/stannous fluoride mouthrinse on supragingival plaque regrowth. J Periodontol 2008;79:1177-83.
Haffajee AD, Roberts C, Murray L, Veiga N, Martin L, Teles RP, et al.
Effect of herbal, essential oil, and chlorhexidine mouthrinses on the composition of the subgingival microbiota and clinical periodontal parameters. J Clin Dent 2009;20:211-7.
Berchier CE, Slot DE, Van der Weijden GA. The efficacy of 0.12% chlorhexidine mouthrinse compared with 0.2% on plaque accumulation and periodontal parameters: A systematic review. J Clin Periodontol 2010;37:829-39.
Southern EN, McCombs GB, Tolle SL, Marinak K. The comparative effects of 0.12% chlorhexidine and herbal oral rinse on dental plaque-induced gingivitis. J Dent Hyg 2006;80:12.
Shetty S, Pillai S, Sridharan S, Satyanarayan A, Rahul A. Comparative efficacy of Chlorhexidine and a herbal mouthrinse in patients with gingival inflammation – A clinical and microbiological study. Asian J Pharm Technol Innov 2013;1:1-8.
Rahmani ME, Radvar M. The anti-plaque activity of Salvadora persica
and padina essential oil solution in comparison to chlorhexidine in human gingival disease: A randomized placebo-controlled clinical trial. Int J Pharmacol 2005;1:311-5.
Haffajee AD, Yaskell T, Socransky SS. Antimicrobial effectiveness of an herbal mouthrinse compared with an essential oil and a chlorhexidine mouthrinse. J Am Dent Assoc 2008;139:606-11.
Duss C, Lang NP, Cosyn J, Persson GR. A randomized, controlled clinical trial on the clinical, microbiological, and staining effects of a novel 0.05% chlorhexidine/herbal extract and a 0.1% chlorhexidine mouthrinse adjunct to periodontal surgery. J Clin Periodontol 2010;37:988-97.
Malhotra R, Grover V, Kapoor A, Saxena D. Comparison of the effectiveness of a commercially available herbal mouthrinse with chlorhexidine gluconate at the clinical and patient level. J Indian Soc Periodontol 2011;15:349-5.
Nadkerny PV, Ravishankar PL, Pramod V, Agarwal LA, Bhandari S. A comparative evaluation of the efficacy of probiotic and chlorhexidine mouthrinses on clinical inflammatory parameters of gingivitis: A randomized controlled clinical study. J Indian Soc Periodontol 2015;19:633-9.
Mali AM, Behal R, Gilda SS. Comparative evaluation of 0.1% turmeric mouthwash with 0.2% chlorhexidine gluconate in prevention of plaque and gingivitis: A clinical and microbiological study. J Indian Soc Periodontol 2012;16:386-91.
[Table 1], [Table 2]