|Year : 2015 | Volume
| Issue : 3 | Page : 277-281
Are herbal mouthwash efficacious over chlorhexidine on the dental plaque?
Devanand Gupta1, Swapna Nayan2, Harshad K Tippanawar3, Gaurav I Patil4, Ankita Jain5, Rizwan K Momin6, Rajendra Kumar Gupta7
1 Department of Public Health Dentistry, Institute of Dental Science, Bareilly, Uttar Pradesh; General Secretary, International Society for Holistic Dentistry, Uttrakhand, India
2 Department of Oral and Maxillofacial Surgery, D.Y Patil Dental College, Nerul, Navi Mumbai, Maharashtra, India
3 Department of Conservative, Endodontics and Esthetics Dentistry, JSS Dental College and Hospital, Mysore, India
4 Department of Orthodontics and Dentofacial Orthopaedics, JSS Dental College and Hospital, Mysore, India
5 Department of Public Health Dentistry, Teerthanker Mahaveer Dental College and Research Centre, Moradabad, India
6 Department of Oral Pathology, Jaipur Dental College, Jaipur, India
7 Principal, Government Degree college, Banbasa, Uttrakhand, India
|Date of Submission||18-Mar-2015|
|Date of Acceptance||23-Mar-2015|
|Date of Web Publication||02-Jun-2015|
Dr. Devanand Gupta
Assistant Professor, Department of Public health Dentistry, Institute of Dental Science, Bareilly, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Aim: To compare the effect of herbal extract mouthwash and chlorhexidine mouthwash on the dental plaque level. Materials and Methods: The subjects (60 healthy medical students aged ranges between 20 and 25 years) were randomly divided into two groups, that is, the herbal group and the chlorhexidine gluconate mouthwash group. The data were collected at the baseline and 3 days. The plaque was disclosed using erythrosine disclosing agent and their scores were recorded using the Quigley and Hein plaque index modified by Turesky-Gilmore-Glickman. Statistical analysis was carried out later to compare the effect of all the two groups. Results: Our result showed that the chlorhexidine group shows a greater decrease in plaque score followed by herbal extract, but the result was statistically insignificant. Conclusion: The results indicate that herbal mouthwash may prove to be an effective agent owing to its ability to reduce plaque level, especially in low socioeconomic strata.
Keywords: Chlorhexidine, herbal mouthwash, holistic dentistry, plaque index
|How to cite this article:|
Gupta D, Nayan S, Tippanawar HK, Patil GI, Jain A, Momin RK, Gupta RK. Are herbal mouthwash efficacious over chlorhexidine on the dental plaque?. Phcog Res 2015;7:277-81
|How to cite this URL:|
Gupta D, Nayan S, Tippanawar HK, Patil GI, Jain A, Momin RK, Gupta RK. Are herbal mouthwash efficacious over chlorhexidine on the dental plaque?. Phcog Res [serial online] 2015 [cited 2019 Aug 24];7:277-81. Available from: http://www.phcogres.com/text.asp?2015/7/3/277/155874
| Introduction|| |
Oral diseases have a strong history of treating by natural remedies. Dental caries and periodontal diseases are essentially caused by the micro-organisms present in dental plaque. Research has linked these micro-organisms, particularly those with adherent biofilm properties, to clinically specific oral conditions, such as caries, periodontal disease and halitosis.  Individual's susceptibility to dental and periodontal disease is dependent on a complex combination of risk factors; including genetics, systemic factors, diet and oral hygiene. Clinical control of these diseases can most readily be achieved by reducing the oral microbial load of the plaque biofilm. Plaque reduction has been the hallmark of preventive dentistry since the advent of antibiotics and the realization that bacteria are possible causative agents of the major dental diseases, caries and periodontal disease. 
Both chemical and mechanical oral hygiene aids are used for removal and prevention of plaque. Mechanical plaque control measures, such as toothbrushes, dental floss, toothpicks, and interdental brushes are very popular and are mostly used in conjunction with chemical plaque control aids. Even though, the toothbrush is the most widely used oral hygiene aid, a majority of the population is not able to perform mechanical plaque removal effectively. Hence, there is the need for chemical plaque control. Chemical methods of reducing plaque, such as mouthwashes, are therefore appealing as they can provide significant benefits to patients who cannot maintain adequate mechanical plaque control. They can be considered a less technically demanding adjuvant to mechanical control.
From the earliest times, plants have not only provided food, cosmetics and embalming ointments, but also a plethora of easily available remedies for the maladies of humanity.  Plants have been exploited by humans for many centuries as sources of medicinal drugs, due to the presence of various bioactive compounds. As the popularity of these herbal products continues to rise, dental professionals are expected to provide information to patients about these products' safety and efficacy. This can be difficult, however, owing to a lack of professional consensus on the subject. Until today, an insufficient amount of clinical research on herb-based mouthrinses and dentifrices has been reported in Asia, especially in India and other southeast Asian countries (where these products are most popular and widely used).
Various mouth rinses are available in the market, amongst which Chlorhexidine is the most popular. It is recognized as the primary agent for chemical plaque control, its clinical efficacy being well known to the profession. It has also been recognized by the pharmaceutical industry as the positive control against which the efficacy of alternative antiplaque agents should be measured, and has earned its eponym of gold standard. But it cannot be used on a long term basis because of various side effects like brown discoloration, taste perturbation, oral mucosal lesions, parotid swelling, enhanced supragingival plaque formation and sometimes unacceptable taste. , An effective alternative to Chlorhexidine with all the good qualities and sans its unpleasant effects is highly desirable and has been long awaited. Herbal mouthwash may act as a good and cost-effective oral hygiene product.
The history of drug development has its foundation firmly set in the study of natural remedies used to treat human disease over centuries. Many studies have found that Cinnamon and Terminalia chebula have antibacterial and antifungal properties. , However, no study had been conducted to check the antiplaque properties of Cinnamon and T. chebula extract in combination. Hence, the present study has been conducted to check the effect of this combination on the clinical level of dental plaque.
| Materials and Methods|| |
This double-blind randomized control trial was conducted in the department of public health dentistry on volunteered university students of Teerthanker Mahaveer University. All subjects signed an Institutional Review Board approved consent form.
Inclusion and exclusion criteria
The students with no history of any dental treatment, antibiotic or anti-inflammatory drug therapy for the past 3 months were included in the study. Those volunteers who had used antibiotics or mouthwash for 5 consecutive days or corticosteroids in the past 30 days were excluded from the study. Furthermore, those who had undergone professional measures to remove plaque and calculus in the past 15 days, and did not give consent for the clinical trial were excluded.
Sample size and randomization
A sampling frame (n = 60) was prepared from the students of Teerthankar Mahaveer University of those who fulfilled the inclusion and exclusion criteria. A total of 60 volunteers were randomly allocated into the two study groups through computer-generated random numbers. Random allocation of mouth rinses using the lottery method was done.
Group 1 (n = 30) was given herbal mouthwash (combination of Cinnamon and T. chebula extract mouthwash) and instructed to use 10 ml twice a day for 3 days.
Group 2 (n = 30) was given chlorhexidine (.12%) and instructed to use 10 ml twice a day for 3 days.
Herbal mouthwash composed of 50% concentration of T. chebula and remaining 50% was the Cinnamon extract. All the students were subjected to scaling and polishing to get the baseline score to nil. All the two groups followed same oral hygiene instructions, except for the use of allocated mouthrinse. Both the mouthrinse were made identical. This was done with the help of Department of Pharmacy, TMU. Students in all the two groups were instructed to rinse their mouth with 10 ml of mouthwash twice daily after breakfast and other after lunch for 3 days for 1 min and not to rinse with water thereafter.
The data were collected at the end of 3 rd day. The plaque was disclosed using erythrosine disclosing agent and their scores were recorded per tooth using the Quigley and Hein plaque index modified by Turesky-Gilmore-Glickman. 
A single examiner, who was trained and calibrated to record the plaque and gingival scores, recorded the findings at all two intervals and for both the groups. The recorder was blinded to the type of the mouthwash used by participants.
The data were analyzed using SPSS version 17. ANOVA followed by post-hoc least significant difference (LSD) were used for analysis. P value of 0.05 was taken to be significant.
| Results|| |
There were no reports of adverse reactions to any of the mouth rinses used. ANOVA was used to analyze the reduction in plaque in the two groups. A significant decrease was noted in the plaque in both the herbal and chlorhexidine groups at 3 days (P < 0.05). There was a progressive decrease in the plaque at 5% level of significance. Chlorhexidine group showed maximum decease when compared to the herbal group, but it was not statistically significant. Multiple comparisons were obtained by post-hoc LSD. The difference in the decrease in plaque (P = 0.309 at 3 days) between herbal group and chlorhexidine group was not statistically significant. Data show that there was no significant difference between herbal-based mouth rinse and chlorhexidine for any clinical parameters throughout the study.
| Discussion|| |
It is generally accepted that the formation of dental plaque at the tooth/gingiva interface is one of the major causes of gingival inflammation and caries. The single best way to remove harmful plaque from teeth is to brush teeth regularly and appropriately. Brushing teeth with toothpaste helps to remove plaque, resist decay, promote remineralization, polish and remove stains, etc. There is an increase in the use of mechanical and chemical plaque control agents to prevent dental caries and periodontal disease. Some of the methods are proper and regular tooth-brushing, flossing and rinsing with mouthwashes. Various chemical mouthwashes are available in the market, but are associated with side-effects such as immediate hypersensitivity reactions, toxicity, tooth staining, etc., Alternative medicines may be developed from medicinal plants as these plants contain natural phytochemicals, and hence, can replace synthetic drugs.
T. chebula is rightly called the 'King of Medicines' in Tibet and is always listed first in Ayurvedic Materia Medica in India. T. chebula fruit has been used as a traditional medicine against various human ailments since antiquity. It exerts a wide range of pharmacological effects. Animal studies have also shown that it exerts anticarcinogenic and antimutagenic effects. In addition, it exerts cardioprotective, hepatoprotective and radioprotective effects.  Cinnamon (Cinnamomum zeylanicum) is one of the herb which has been used extensively for treatment of several conditions including general and oral health. In traditional medicine cinnamon is used for colds, flatulence, nausea and diarrhea. It's also believed to improve energy, vitality, and circulation. Studies have found that cinnamon may have antibacterial and antifungal properties.
Two studies have claimed T. chebula as an antiplaque agent. , However, until date, a comparison of the clinical antiplaque effectiveness of the combination of T. chebula with Cinnamon and 0.12% chlorhexidine has not been reported in controlled trials. As far as we know, this is the first published trial that directly compared the antiplaque efficacy of combination of T. chebula and Cinnamon extract mouthwash and chlorhexidine rinses, which limits the possibility of comparison with the literature.
Terminalia chebula extracts exerts antibacterial, antiviral effect against Helicobactor pylori, Xanthomonas campestris pv. citri and Salmonella More Details typhi, herpes simplex virus type-1, human immunodeficiency virus-1 and Cytomegalovirus. T. chebula contains almost 30% tannins and other minor constituents are polyphenols such as corilagin, galloyl glucose, punicalagin, terflavin A and maslinic acid. Tannins are a group of polymeric phenolic substances of pyrogallol (hydrolysable) types, releasing gallic acid as a main component, which is well recognized for its antimicrobial and astringent property. 
According to Ooi et al.  Cinnamon is active on Gram-positive and Gram-negative bacteria. Cinnamaldehyde is the major and active component in Cinnamon. 
The in vitro study conducted by Fani, Kohanteb showed that Cinnamon oil showed strong, promising inhibitory activity on all the Streptococcus mutans isolates at a concentration of as low as 3.12%.  T. chebula alone may also act as an antiplaque agent. 
Mechanisms where by cinnamon extract inhibit growth of bacteria especially against oral bacteria are still unclear, most explanations concerning the antibacterial effect of cinnamon in general related the inhibitory effect of cinnamon to its essential oils. An important characteristic of essential oils and their components is their hydrophobicity, which enable them to partition the lipids of the bacterial cell membrane, disturbing the cell structures and rendering them more permeable. Extensive leakage from bacterial cells or the exit of critical molecules and ions will lead to death. 
Most of the studies on Cinnamon oil suggest that it is not harmful and may be used as an agent to inhibit the growth of bacteria, fungi, and yeast. However, some cases of contact dermatitis and stomatitis associated with Cinnamon oil have been reported.  Cinnamon is rarely associated with allergic reactions with symptoms like localized burning sensation, sloughing, erythema. 
In the present study, combination of T. chebula and Cinnamon was used. 50% T. chebula extract and 50% Cinnamon was used to make the mouthwash, which acted as antiplaque agent.
The efficacy of combination of cinnamon and T. chebula has never been tested on the dental plaque level. No studies had been conducted to show the effect of combination of Cinnamon and T. chebula extract on plaque which is the main precursor of periodontal diseases.
In the present study, there was a significant difference on the clinical level of dental plaque in both herbal and chlorhexidine mouthwash group before and after the experimental period. Chlorhexidine shows more reduction in dental plaque than herbal extract, but the result was statistically insignificant. The results of these two groups on plaque could not be compared with other studies as no studies have been reported in the literature, which has tried to assess the same effect. Thus it can be said that the holistic or complementary medicine has a great potential which can be utilized for the better oral and general health. ,,,,,,,,,,,,,,,
Present study was a short term study employing a crude extract of T. chebula and Cinnamon as mouthrinse. Though significant results were obtained at 3 days in the herbal groups, long term clinical efficacy (6 months -as prescribed by ADA)  and adverse effects associated with long term usage could not be assessed. Microbiological assessment on plaque or saliva of the participants was not performed and hence this study could not provide any evidence regarding the effects of these mouthwashes on oral microbial flora.
| Conclusion|| |
Within the limitation of this trial, herbal mouthwash has been shown to demonstrate similar effects on a plaque as compared to the standard drug chlorhexidine. Further, long term research needs to be done to check the efficacy and effectiveness of herbal products over standard drug regime. Given the increasing trend in Ayurveda use in day today life and the enormous power to two contemporary approaches - evidence-based clinical practice and modern dentistry - the time is ripe to reformulate our approach to the practice, research and training in Ayurveda and holistic dentistry. Natural compounds can again become central players in the treatment of disease and in the understanding of disease mechanisms.
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