ORIGINAL Gupta ARTICLE et al
Comparative Evaluation of Terminalia chebula Extract Mouthwash and Chlorhexidine Mouthwash on Plaque and Gingival Inflammation – 4-week Randomised Control Trial Devanand Guptaa/Rajendra Kumar Guptab/Dara John Bhaskarc/Vipul Guptad Purpose: The present study was conducted to assess the effectiveness of Terminalia chebula on plaque and gingival inflammation and compare it with the gold standard chlorhexidine (CHX 0.2%) and distilled water as control (placebo). Materials and Methods: A double-blind randomised control trial was conducted among undergraduate students who volunteered. They were randomly allocated into three study groups: 1) Terminalia chebula mouthwash (n = 30); 2) chlorhexidine (active control) (n = 30); 3) distilled water (placebo) (n = 30). Assessment was carried out according to plaque score and gingival score. Statistical analysis was carried out to compare the effect of both mouthwashes. ANOVA and post-hoc LSD tests were performed using SPSS version 17 with p ≤ 0.05 considered statistically significant. Results: Our result showed that Terminalia chebula mouthrinse is as effective as chlorhexidine in reducing dental plaque and gingival inflammation. The results demonstrated a significant reduction of gingival bleeding and plaque indices in both groups over a period of 15 and 30 days as compared to the placebo. Conclusion: The results of the present study indicate that Terminalia chebula may prove to be an effective mouthwash. Terminalia chebula extract mouthrinse can be used as an alternative to chlorhexidine mouthrinse as it has similar properties without the side-effects of the latter. Key words: chlorhexidine, oral health, periodontal index, Terminalia chebula Oral Health Prev Dent 2015;13:5-12 doi: 10.3290/j.ohpd.a32994
G
ood oral health has a major influence on one’s general quality of life and well-being. Several chronic and systemic diseases have been attributed to poor oral health. With the increasing incidence of oral diseases, the global need for alternaa
Assistant Professor, Institute of Dental Science, Bareilly, Uttar Pradesh, India. Experimental design, performed the experiments in partial fulfillment of requirements for a degree, wrote the manuscript.
b
Principal, Government Degree College, Banbasa (Champawat), India. Idea, hypothesis, contributed substantially to discussion.
c
Professor and Head, Department of Public Health Dentistry, Teerthankar Mahaveer Dental College and Research Centre, Moradabad, Uttar Pradesh, India. Proofread the manuscript.
d
Assistant Professor, Department of Public Health Dentistry, Teerthankar Mahaveer Dental College and Research Centre, Moradabad, Uttar Pradesh, India. Proofread the manuscript, performed a certain test.
Correspondence: Dr. Devanand Gupta, Department of Public Health Dentistry, Teerthankar Mahaveer Dental College and Research Centre, Moradabad, Uttar Pradesh, India. Tel: +91-889-9746798. Email: [email protected]
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Submitted for publication: 04.02.13; accepted for publication: 09.03.13
tive prevention and treatment methods as well as safe, effective and economical products has expanded; the use of plants – which have a long medicinal history – to improve dental health and promote oral hygiene falls into this category. (Gupta et al, 2014a). Destructive periodontal diseases are characterised by loss of the supporting tissues of teeth, and they are recognised as major public health problems worldwide. Epidemiological studies have shown that periodontal diseases are among the most common afflictions of mankind (Petersen et al, 2005). The most effective method of prevention and maintenance of periodontal diseases is mechanical oral hygiene combined with proper professional maintenance. From this perspective, the utilisation of antimicrobial mouthrinses has been considered a useful adjunct to oral hygiene. Several compounds have been evaluated for their effectiveness on supragingival plaque and gingivitis, including bisbiguanides such as chlorhexidine gluconate (Van Strydonck et al, 2012), essential
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oils (Botelho et al, 2007), phenolic compounds, pyrimidines, quaternary ammonium compounds, oxygenating agents, halogens etc. Among these agents, chlorhexidine is thus far the most studied and effective antiseptic for plaque inhibition and prevention of gingivitis when used twice daily as a mouthrinse (Herrera, 2013). However, many of the currently available mouthrinses have drawbacks, such as alteration in taste sensation and staining of teeth (Twetman, 2004). In order to overcome such side effects, the World Health Organization (WHO) advised researchers to investigate the possible use of natural products such as herb and plant extracts. Such extracts have been used in oral hygiene products for many years all over the world (Gupta et al, 2014b,c). Several conventional anti-plaque agents are available on the market, but with the rise in resistance to antibiotics, there is considerable interest in the development of herbal alternatives for the control of infection (Gupta et al, 2013). A number of clinical studies have shown the effects of using mouthwashes extracted from herbs such as Myrtus communis (Hedayati et al, 2013), Quercus infectoria (Vermani and Prabhat, 2009) Occimum sanctum (Gupta et al, 2014d), Triphala (Chainani et al, 2014), Aloe vera (Gupta et al, 2014; Karim et al, 2014) and Capparis spinosa (Al-Bayaty et al, 2010) in the prevention of dental plaque accumulation and subsequent gingival inflammation. Medicinal plants used to combat diseases have been an integral part of human societies from the dawn of civilisation. Terminalia chebula Retz. (Fam. Combretaceae) is called the ‘King of Medicine’ in Tibet and is always at the top of the list of ‘Ayurvedic Materia Medica’ because of its extraordinary healing power (Nayak et al, 2010). The whole plant possesses high medicinal value and is traditionally used for the treatment of various ailments, such as asthma, sore throat, vomiting, hiccough, diarrhoea, dysentery, bleeding haemorrhoids, ulcers, gout, heart and bladder diseases. The plant has been demonstrated to possess multiple pharmacological and medicinal properties, such as antioxidant, antimicrobial, antidiabetic, hepatoprotective, anti-inflammatory, antimutagenic, antiproliferative, radioprotective, cardioprotective, antiarthritic and anticaries activity, as well as promoting gastrointestinal motility and wound healing. On examining the list of plants recommended for a particular dental therapeutic purpose, it is evident that the ripe fruit of Terminalia chebula is valuable in the prevention and treatment of several diseases of the mouth, such as dental
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caries, spongy and bleeding gums, gingivitis and stomatitis (Kathirvel and Sujatha, 2012). This study was hence planned with the objective of clinically evaluating the efficacy of Terminalia chebula in preventing plaque accumulation and gingival inflammation. It was also compared with a commercially available chlorhexidine 0.2% (CHX) mouthwash and distilled water (placebo).
MATERIALS AND METHODS In this placebo-controlled, double-blind randomised control trial, three groups were studied in parallel at the Department of Public Health Dentistry. The volunteer participants were undergraduate students of the Teerthankar Mahaveer Dental College and Research Centre. The study protocol was approved by the Institutional Review Board (IRB) of Teerthankar Mahaveer University and all subjects signed an IRB-approved consent form. A pilot study was done on 5 patients in each group to check the feasibility of the study; those results are not included in the present study.
Preparation of extract The ripe fruit (400 g) was suspended in 10 times its quantity of sterile distilled water in a round-bottomed flask and kept at 4°C for 72 h. The aqueous extract was decanted, clarified by filtration through a muslin cloth and evaporated in a porcelain dish at 40°C, which resulted in the dried extract. The extract was suspended in polyethylene glycol 400 (20% v:v) and sterile distilled water to yield a final concentration of 30% w:v. The concentrated extract was diluted with sterile distilled water to produce a mouthrinse concentration of 10% (w:v). As a flavouring agent, 0.05% spearmint oil was added.
Inclusion and exclusion criteria Students with no history of any dental treatment, antibiotic or anti-inflammatory drug therapy for the past 3 months were included in the study. Students with any of history systemic diseases or conditions, fibrotic gingival enlargement and smoking were excluded from the study. Participants with good general health, a baseline plaque score greater than 1.5 and a baseline DMFT index of 3 to 5 were included in the study. Those volunteers who had used
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antibiotics or mouthwash for 5 consecutive days or corticosteroids in the past 30 days were excluded from the study. Those subjects who had a history of sensitivity to any mouthwash or used removable prostheses or an orthodontic appliance were excluded from the study. Also, those who had undergone professional measures to remove plaque and calculus in the past 15 days as well as those who did not give consent for the clinical trial were excluded.
Sample size and randomisation All the undergraduate dental students of Teerthankar Mahaveer Dental College and Research Centre were subjected to clinical examination, and a sampling frame (n = 237) was prepared of those who fulfilled the inclusion and exclusion criteria. A sample size of 90 was arrived at by using NMaster Statistical Software (Department of Biostatistics, CMC; Vellore, India). A total of 90 volunteers were randomly allocated into the three study groups through computer-generated random numbers. Random allocation of mouthrinses using the lottery method was done. Individuals were identified by code numbers throughout the study. This clinical trial was conducted according to ADA guidelines 1997, Adjunctive Dental Therapies (Council on Scientific Affairs, 1997). None of the eligible subjects refused to participate in the study. • Group 1 (n = 30) was given 10% Terminalia chebula mouthwash and instructed to use 10 ml twice a day for 30 days. • Group 2 (n = 30) was given 0.2% CHX and instructed to use 10 ml twice a day for 30 days. • Group 3 (n = 30) was the placebo control group and distilled water was given as the mouthwash. All three solutions were made the same colour with the help of the pharmacy department, kept in coded containers and decoded later. Students were instructed to rinse their mouth for 60 s with 10 ml of mouthwash twice daily without subsequent rinsing with water, once after breakfast and once after lunch, for 30 days. Data were collected three times in 30 days for assessing plaque and gingivitis. Clinical measurements for plaque and gingivitis were taken at baseline (prior to the study), 15 days and at the end of the study (4 weeks) using a mouth mirror, explorer, disclosing agent, periodontal probe and tweezers, and were recorded on chart. Study subjects, the investigators and assistants involved
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in the trial were masked with respect to the treatment. During the 30 days of the trial, the subjects continued to exercise their regular non-supervised, self-performed plaque control measures. No oral prophylaxis was done before the start of the study. A single examiner trained and calibrated to record the plaque and gingival scores recorded the findings at all three intervals. Intra-examiner reliability was assessed within an interval of 60 min. Using kappa statistics, intra-examiner reliability was 0.78 for the gingival index and 0.82 for the plaque index. The recorder was blinded to the type of the mouthwash used by participants. None of the parameters – gender, smoking status, level of education, monthly family income, number of teeth present, plaque index, gingival index and gingival bleeding index – were not significantly different between the groups at baseline (all p > 0.1).
Plaque and gingivitis analysis Supragingival plaque was scored according to the Turesky modification of the Quigley-Hein plaque index (Turesky et al, 1970). Scoring of gingival inflammation (gingivitis) was done using the Löe and Silness (1963) gingival index.
Statistical analysis The data were analysed using SPSS version 17. ANOVA was used to analyse the reduction in plaque and gingivitis in the three groups, as well as to assess the intra- and inter-group variations for plaque and gingivitis. This was followed by the post-hoc LSD test to obtain multiple comparisons. A p-value of 0.05 was taken to be significant.
RESULTS All participants in all study groups completed the study. Descriptive baseline statistics are presented in Table 1. The mean ± SD plaque and gingival scores for the Terminalia chebula, CHX and placebo groups are presented in Table 2. ANOVA showed a signifi cant progressive decrease in the plaque and gingivitis scores in both the Terminalia chebula and CHX groups at 15 and 30 days (p < 0.05) (Table 3). The greatest decease was seen in the CHX group, but compared to the Terminalia chebula group, the dif-
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Table 1 Baseline background of the subjects Group 1 (Terminalia chebula)
Group 2 (CHX)
Group 3 (Placebo)
Total number of participants
30
30
30
Age (mean 21.75 years; range 18–27 years)
22.16
21.71
22.13
Frequency of brushing: once daily
22
20
24
Frequency of brushing: twice daily
8
10
6
Other oral hygiene aids used
None
None
None
Rinsing habit
None
None
None
DMFT (mean = 4.5)
4.7
4.5
4.0
Table 2 Plaque and gingivitis score at baseline and after 15 and 30 days Group 1
Group 2
Group 3
Baseline
15th day
30th day
Baseline
15th day
30th day
Baseline
15th day
30th day
Mean
3.00
2.81
2.59
2.89
2.63
2.38
2.98
3.19
3.22
Standard deviation
0.44
0.44
0.46
0.54
0.57
0.57
0.58
0.56
0.56
Range
1.91
1.91
1.91
2.29
2.33
2.33
2.76
2.69
2.69
Mean
2.33
1.70
1.45
2.36
1.66
1.31
2.38
2.40
2.42
Standard deviation
0.43
0.36
0.36
0.45
0.41
0.40
0.49
0.49
0.49
Range
1.00
1.10
1.10
1.00
1.20
1.06
1.00
1.00
1.00
Plaque index
Gingival index
ference was not statistically significant. Rinsing with distilled water (group 3, control) was associated with increased plaque scores. The post-hoc LSD showed that the difference in the decrease in plaque (p = 0.592 at 15 days and p = 1.096 at 30 days; Table 4) and gingivitis (p = 0.837 for 15 days and p = 0.909 for 30 days; Table 5) between Terminalia chebula and CHX groups was not statistically significant. However, the difference between Terminalia chebula and the control group and CHX and the control group was significant (p < 0.05). The data show that there was no significant difference between the Terminalia chebula-based mouthrinse and CHX for any clinical parameters throughout the study.
DISCUSSION This study was conducted on volunteer undergraduate dental students in the Department of Public Health Dentistry, Teerthanker Mahaveer Dental
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College and Research Centre, Moradabad, India over a period of 30 days. Our data show that a mouthrinse based on Terminalia chebula is equally effective in reducing dental plaque and gingivitis as chlorhexidine. In terms of study design, a double-blind controlled clinical trial was chosen, in keeping with the proposal by Overholser Jr. (1988) that clinical studies to evaluate the effectiveness of antimicrobial mouthrinses should be double blind. The undergraduate student volunteers did not discontinue their routine oral hygiene practices during the study. This is similar to the study design used by Axelsson and Lindhe (1987) in a 6-week trial where the subjects continued to exercise their regular non-supervised, self-performed plaque control measures. In the present study, participants were instructed to rinse their mouth with 10 ml of solution for a period of 1 min after lunch and then were told not to rinse their mouth with water or drink anything for half an hour. A similar amount and du-
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Table 3 ANOVA of the three study groups Sum of Squares
Df
Mean Square
F
Sig.
Plaque, baseline
Between groups Within groups
8.170 22.917
2 78
3.761 0.371
11.198
0.681
Plaque, 15 days
Between groups Within groups
2.709 21.190
2 78
1.371 0.319
6.078
0.004
Plaque, 30 days
Between groups Within groups
2.917 22.191
2 78
1.017 0.337
2.009
0.002
Gingivitis, baseline
Between groups Within groups
1.717 14.113
2 78
0.607 0.597
0.871
0.218
Gingivitis, 15 days
Between groups Within groups
3.981 21.194
2 78
3.045 0.307
22.891
0.002
Gingivitis, 30 days
Between groups Within groups
2.819 22.173
2 78
9.711 0.214
50.107
0.017
Table 4 Post-hoc LSD test for multiple comparisons, plaque 95% Confidence interval Variable
Plaque, baseline
(I) Group
(J) Group
Std. Error
Sig.
Lower limit
Upper limit
T. chebula
CHX Placebo T. chebula Placebo T. chebula CHX
0.1890 0.1890 0.1890 0.1890 0.1890 0.1890
0.598 0.312 0.598 0.408 0.312 0.404
-0.012 0.521 -.625 .274 -1.112 -0.791
0.625 1.112 0.012 .791 -0.521 -0.274
CHX Placebo T. chebula Placebo T. chebula CHX
0.1512 0.1512 0.1512 0.1512 0.1512 0.1512
0.592 0.021 0.592 0.029 0.021 0.029
0.082 0.219 -0.721 -0.273 -0.972 -0.479
0.721 0.972 -0.082 0.479 -0.219 0.273
CHX Placebo T. chebula Placebo T. chebula CHX
0.1596 0.1596 0.1596 0.1596 0.1596 0.1596
1.096 0.029 1.096 0.020 0.029 0.020
0.081 -0.162 -0.764 -0.881 -0.481 -0.079
0.764 0.481 -0.081 0.079 0.162 0.811
CHX Placebo T. chebula
Plaque, 15 days
CHX Placebo T. chebula
Plaque, 30 days
CHX Placebo
(I) and (J) designations according to post-hoc analysis by SPSS. The mean difference is significant at the 0.05 level.
ration of mouthwash administration was followed in a study conducted by Gupta et al (2014d). The CHX preparation used in this study did not contain alcohol. Leyes et al (2002) stated that the alcohol-free rinse was as effective as one containing alcohol in controlling plaque and reducing gingival inflammation. CHX gluconate has a long history in dental medicine. Unfortunately, studies have shown that these positive effects are accompanied by side-effects, the most disturbing being extrinsic tooth staining and others such as unpleasant taste and burning sensation (Venkatesh Babu et al, 2011). Menendez et al (2005) found that a lower
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concentration of chlorhexidine (0.12%) may not be sufficiently effective compared with other concentrations, i.e. 0.2%. Hence, in this study, a concentration of 0.2% was used. T. chebula is an important medicinal plant in Indian traditional medicine and it is the most frequently used herb in Ayurveda. The antibacterial activity of T. chebula extracts against several bacterial strains has been reported (Chattopadhyay et al, 2007; Bag et al, 2009). It is effective in inhibiting Helicobactor pylori (Zaidi et al, 2012), Xanthomonas campestris pv. citri (Cheema et al, 2013) and Salmonella typhi (Gupta et al, 2013). It pos-
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Table 5 Post-hoc LSD test for multiple comparisons, gingivitis 95% Confidence interval Dependent variable
Group
(I)
Mean difference(I-J)
Std. Error
Sig.
Lower limit
Upper limit
CHX
-0.1296
0.12692
0.036
-0.3823
0.1231
Placebo
-0.1667
0.12692
0.042
-0.4193
0.0860
T. chebula
0.1296
0.12692
0.036
-0.1231
0.3823
Placebo
-0.0370
0.12692
0.032
-0.2897
0.2156
T. chebula
0.1667
0.12692
0.042
-0.0860
0.4193
CHX
0.0370
0.12692
0.032
-0.2156
0.2897
CHX
-0.1252
0.11768
0.083
-0.3595
0.1091
Placebo
-0.7981
0.11768
0.030
-1.0324
-0.5639
T. chebula
0.1252
0.11768
0.083
-0.1091
0.3595
Placebo
-0.6730
0.11768
0.020
-0.9072
-0.4387
T. chebula
0.7981
0.11768
0.030
0.5639
1.0324
CHX
0.6730
0.11768
0.020
0.4387
0.9072
CHX
-0.0837
0.11685
0.102
-0.3163
0.1489
Placebo
-1.0481
0.11685
0.020
-1.2808
-0.8155
T. chebula
0.0837
0.11685
0.102
-0.1489
0.3163
Placebo
-0.9644
0.11685
0.010
-1.1971
-0.7318
T. chebula
1.0481
0.11685
0.020
0.8155
1.2808
CHX
0.9644
0.11685
0.010
0.7318
1.1971
Group
(J)
T. chebula
Gingivitis, baseline
CHX
Placebo
T. chebula
Gingivitis (15 days)
CHX
Placebo
T. chebula
Gingivitis (30 days)
CHX
Placebo (I), (J)
Designations according to post-hoc analysis by SPSS. The mean difference is significant at the 0.05 level.
sesses antiviral activity against herpes simplex virus type-1 (HSV-1), human immunodeficiency virus-1 (HIV-1) and Cytomegalovirus (Gupta et al, 2013). Terminalia chebula contains almost 30% tannins, which are a group of polymeric phenolic substances. Terminalia chebula extract, with tannin as its active compound, is well recognised for its anticaries and anti-microbial activity as well as its astringent property. Some studies have reported that tannic acid is bacteriostatic or bactericidal to some Gram-negative and Gram-positive pathogens (Iqbal et al, 1998). In group 3, where distilled water was used as the mouthrinse, plaque was found to increase as compared to the baseline score. In the present study, there was no significant difference between CHX and Terminalia chebula mouthwash in terms of plaque and gingivitis scores. Review of the available literature has revealed that no studies have been conducted to assess the effect of Terminalia chebula on plaque and gingivitis,
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although a few studies have assessed the effect of Terminalia chebula on salivary pH and as an anticaries agent. Jagtap and Karkera (1999) analysed the effect of various concentrations of the Terminalia chebula extract ranging from 2% to 30% and found that a 10% concentration of the extract was optimum; thus, in the present study, a concentration of 10% was used. The results of 10% Terminalia chebula extract mouth rinse on plaque and gingivitis could not be compared with other studies, as no other studies on this exist. This makes the present study unique. However, some authors (Bag et al, 2013) suggest that Terminalia chebula possesses other remarkable properties for general and oral health. In addition, Terminalia chebula extract possesses substantivity, which is an essential prerequisite for an ideal mouthrinse (Jagtap and Karkera 1999).
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CONCLUSIONS Terminalia chebula is one of the most versatile medicinal plants, having a wide spectrum of pharmacological activity. This study showed that Terminalia chebula reduced plaque and gingivitis to an extent equivalent to that of the benchmark control chlorhexidine. T. chebula mouthwash has some advantages over CHX: it is much less expensive than the commercially available chlorhexidine mouthwash, is easily accessible and, being an Ayurvedic product, it has no known side-effects and hence is safe for use over a long period of time. These are encouraging results which clearly favour promotion of Terminalia chebula as a mouthrinse for communities, particularly those belonging to low socioeconomic strata. However, as this is the first attempt to assess the effect of Terminalia chebula on plaque and gingivitis, clinical trials of longer duration with a larger sample size should play a vital role in the commercialisation of Terminalia chebula mouthwash. Researchers need to have a fresh look at the field of herbal medicine, as there may be many such plants which potentially possess as-yet scientifcally untested pharmacological activity. Research in the area of herbal medicine is deemed necessary to provide such evidence.
ACKNOWLEDGEMENTS I am highly thankful to my mentor Dr. D.J Bhaskar and Dr. Mary Suvarna for their blessings and support, and also to all the participants for their cooperation.
REFERENCES 1. Al-Bayaty FH, AI-Koubaisi AH, Ali NAW, Abdulla MA. Effect of mouth wash extracted from Salvadora persica (Miswak) on dental plaque formation: A clinical trial. J Medicin Plants Res 2010;4:1446–1454. 2. Axelsson P, Lindhe J. Efficacy of mouth rinses in inhibiting dental plaque and gingivitis in man. J Clin Periodontol 1987;14:205–212. 3. Bag A, Bhattacharyya SK, Bharati P, Pal NK, Chattopadhyay RR. Evaluation of antibacterial properties of Chebulic myrobalan (fruit of Terminalia chebula Retz.) extracts against methicillin resistant Staphylococcus aureus and trimethoprim-sulphamethoxazole resistant uropathogenic Escherichia coli. Afr J Plant Sci 2009;3:25–29. 4. Botelho MA, Bezerra-Filho JG;Correa LL, Heukelbach J. Effect of a novel essential oil mouthrinse without alcohol on gingivitis: a double-blinded randomized controlled trial. J Appl Oral Sci 2007;15:175–180.
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5. Carounanidy U, Satyanarayanan R, Velmurugan A. Use of an aqueous extract of Terminalia chebula as an anticaries agent: a clinical study. Indian J Dent Res 2007;18:152–156. 6. Chainani SH, Siddana S, Reddy C, Manjunathappa TH, Manjunath M, Rudraswamy S. Antiplaque and antigingivitis efficacy of Triphala and Chlorhexidine mouthrinse among schoolchildren – a cross-over, double-blind, randomised controlled trial. Oral Health Prev Dent 2014;12: 209–215. 7. Chattopadhyay RR, Bhattacharyya SK, Medda C, Chanda S, Datta S, Pal NK. Antibacterial activity of black myrobalan (fruit of Terminalia chebula Retz.) against uropathogen Escherichia coli. Phcog Rev 2007;11:212–215. 8. Cheema ZA, Farooq M, Wahid A. Allelopathy: current trends and future applications. Hamburg: Springer, 2013:203–204. 9. Gupta D, Batra R, Mahajan S, Bhaskar DJ, Jain A, Yadav A et al. Comparative evaluation of the complementary and alternative medicine therapy and conventional therapy use from musculoskeletal disorders management and its association with job satisfaction among dentists of West India. J Tradit Complement Med 2014a;4:263–267. 10. Gupta D, Bhaskar DJ, Gupta RK, Jain A, Yadav P, Dalai DR et al. Is complementary and alternative medicine effective in job satisfaction among dentists with musculoskeletal disorders? A cross sectional study. Medycyna Pracy 2014b;65:317–323. 11. Gupta D, Bhaskar DJ, Gupta RK, Karim B, Jain A, Singh R, et al. A randomized controlled clinical trial of Ocimum sanctum and chlorhexidine mouthwash on dental plaque and gingival inflammation. J Ayurveda Integr Med 2014d;5:109–116. 12. Gupta D, Bhaskar DJ, Gupta RK, Karim B, Kanwar A, Jain A, et al. Use of complementary and alternative medicine for work related musculoskeletal disorders associated with job contentment in dental professionals: Indian outlook. Ethiop J Health Sci 2014c:24;117–124. 13. Gupta D, Bhaskar DJ, Gupta RK. Contemporary and alternative dentistry: Ayurveda in dentistry. Saarbrücken: Lap Lambert Academic Publishing, 2013:28–30. 14. Gupta RK, Gupta D, Bhaskar D, Yadav A, Obaid K, Mishra S. Preliminary antiplaque efficacy of aloe vera mouthwash on 4 day plaque re-growth model: Randomized control trial. Ethiop J Health Sci 2014;24:139–144. 15. Hedayati A, Hengameh K, Bazargani A, Abed M, Emami A. Assessing the antimicrobial effect of the essential oil of Myrtus communis on the clinical isolates of Porphyromonas gingivalis: An in vitro study. Jundishapur J Natural Pharmaceut Prod 2013;8:165–168. 16. Herrera D. Chlorhexidine mouthwash reduces plaque and gingivitis. Evid Based Dent 2013;14:17–18. 17. Iqbal A, Zafar M, Faiz M. Screening of some Indian medicinal plants for their antimicrobial properties. J Ethnopharmacol 1998;62:183–193. 18. Jagtap AG, Karkera SG. Potential of the aqueous extract of Terminalia chebula as an anticaries agent. J Ethnopharmacol 1999;68:299–306. 19. Karim B, Bhaskar D.J, Agali A, Gupta D, Gupta RK, Jain A et al. Effect of Aloe vera mouthwash on periodontal health: triple blind randomized control trial. Oral Health Dent Manag 2014;13:14–19. 20. Kathirvel A, Sujatha V. In vitro assessment of antioxidant and antibacterial properties of Terminalia chebula Retz. leaves. Asian Pacific J Tropic Biomed 2012;2:S788–S795.
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Gupta et al 21. Leyes Borrajo JL, Garcia VL, Lopez CG, Rodriguez-Nunez I, Garcia FM, Gallas TM. Efficacy of chlorhexidine mouthrinses with and without alcohol: A clinical study. J Periodontol 2002;73:317–321. 22. Li F, Menendez A, Michalek SM, Kirk K, Makhiya SK, Childers NK. Comparative analysis of the antibacterial effects of combined mouthrinses on Streptococcus mutans. Oral Microbiol Immunol 2005;20:31–34. 23. Löe H, Silness J. Periodontal disease in pregnancy. I. Prevalence and severity. Acta Odontol Scand 1963;21:533–551. 24. Nayak SS, Ashok Kumar BR, Ankola AV, Hebbal M. The efficacy of Terminalia chebula rinse on Streptococcus mutans count in saliva and its effect on salivary pH. Oral Health Prev Dent 2010;8:55–58. 25. Overholser CD, Jr. Longitudinal clinical studies with antimicrobial mouthrinses. J Clin Periodontol 1988;15:517–519. 26. Petersen PE, Yamamoto T. Improving the oral health of older people: the approach of the WHO Global Oral Health Programme. Community Dent Oral Epidemiol 2005;33:81–92.
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27. Turesky S, Gilmore ND, Glickman I . Reduced plaque formation by the chloromethyl analogue of Victamine C. J Periodontol 1970;41:41–43. 28. Twetman S. Antimicrobials in future caries control. Caries Res 2004;38:223–229. 29. Van Strydonck DA, Slot DE, Van der Velden U, Van der Weijden F. Effect of a chlorhexidine mouthrinse on plaque, gingival inflammation and staining in gingivitis patients: a systematic review. J Clin Periodontol 2012;39:1042– 1055. 30. Venkatesh Babu NS, Vivek DK, Ambika G. Comparative evaluation of chlorhexidine mouthrinse versus cacao bean husk extract mouthrinse as antimicrobial agents in children. Eur Arch Paediatr Dent 2011;12:245–249. 31. Vermani A, Prabhat N. Screening of Quercus infectoria gall extracts as anti-bacterial agents against dental pathogens. Indian J Dent Res 2009;20:337–339. 32. Zaidi SF, Muhammad JS, Shahryar S, Usmanghani K, Gilani AH, Jafri W, Sugiyama T. Anti-inflammatory and cytoprotective effects of selected Pakistani medicinal plants in Helicobacter pylori-infected gastric epithelial cells. J Ethnopharmacol 2012;141:403–410.
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Comparative Evaluation of Terminalia chebula Extract Mouthwash and Chlorhexidine Mouthwash on Plaque and Gingival Inflammation – 4-week Randomised Control Trial Devanand Guptaa/Rajendra Kumar Guptab/Dara John Bhaskarc/Vipul Guptad Purpose: The present study was conducted to assess the effectiveness of Terminalia chebula on plaque and gingival inflammation and compare it with the gold standard chlorhexidine (CHX 0.2%) and distilled water as control (placebo). Materials and Methods: A double-blind randomised control trial was conducted among undergraduate students who volunteered. They were randomly allocated into three study groups: 1) Terminalia chebula mouthwash (n = 30); 2) chlorhexidine (active control) (n = 30); 3) distilled water (placebo) (n = 30). Assessment was carried out according to plaque score and gingival score. Statistical analysis was carried out to compare the effect of both mouthwashes. ANOVA and post-hoc LSD tests were performed using SPSS version 17 with p ≤ 0.05 considered statistically significant. Results: Our result showed that Terminalia chebula mouthrinse is as effective as chlorhexidine in reducing dental plaque and gingival inflammation. The results demonstrated a significant reduction of gingival bleeding and plaque indices in both groups over a period of 15 and 30 days as compared to the placebo. Conclusion: The results of the present study indicate that Terminalia chebula may prove to be an effective mouthwash. Terminalia chebula extract mouthrinse can be used as an alternative to chlorhexidine mouthrinse as it has similar properties without the side-effects of the latter. Key words: chlorhexidine, oral health, periodontal index, Terminalia chebula Oral Health Prev Dent 2015;13:5-12 doi: 10.3290/j.ohpd.a32994
G
ood oral health has a major influence on one’s general quality of life and well-being. Several chronic and systemic diseases have been attributed to poor oral health. With the increasing incidence of oral diseases, the global need for alternaa
Assistant Professor, Institute of Dental Science, Bareilly, Uttar Pradesh, India. Experimental design, performed the experiments in partial fulfillment of requirements for a degree, wrote the manuscript.
b
Principal, Government Degree College, Banbasa (Champawat), India. Idea, hypothesis, contributed substantially to discussion.
c
Professor and Head, Department of Public Health Dentistry, Teerthankar Mahaveer Dental College and Research Centre, Moradabad, Uttar Pradesh, India. Proofread the manuscript.
d
Assistant Professor, Department of Public Health Dentistry, Teerthankar Mahaveer Dental College and Research Centre, Moradabad, Uttar Pradesh, India. Proofread the manuscript, performed a certain test.
Correspondence: Dr. Devanand Gupta, Department of Public Health Dentistry, Teerthankar Mahaveer Dental College and Research Centre, Moradabad, Uttar Pradesh, India. Tel: +91-889-9746798. Email: [email protected]
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Submitted for publication: 04.02.13; accepted for publication: 09.03.13
tive prevention and treatment methods as well as safe, effective and economical products has expanded; the use of plants – which have a long medicinal history – to improve dental health and promote oral hygiene falls into this category. (Gupta et al, 2014a). Destructive periodontal diseases are characterised by loss of the supporting tissues of teeth, and they are recognised as major public health problems worldwide. Epidemiological studies have shown that periodontal diseases are among the most common afflictions of mankind (Petersen et al, 2005). The most effective method of prevention and maintenance of periodontal diseases is mechanical oral hygiene combined with proper professional maintenance. From this perspective, the utilisation of antimicrobial mouthrinses has been considered a useful adjunct to oral hygiene. Several compounds have been evaluated for their effectiveness on supragingival plaque and gingivitis, including bisbiguanides such as chlorhexidine gluconate (Van Strydonck et al, 2012), essential
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oils (Botelho et al, 2007), phenolic compounds, pyrimidines, quaternary ammonium compounds, oxygenating agents, halogens etc. Among these agents, chlorhexidine is thus far the most studied and effective antiseptic for plaque inhibition and prevention of gingivitis when used twice daily as a mouthrinse (Herrera, 2013). However, many of the currently available mouthrinses have drawbacks, such as alteration in taste sensation and staining of teeth (Twetman, 2004). In order to overcome such side effects, the World Health Organization (WHO) advised researchers to investigate the possible use of natural products such as herb and plant extracts. Such extracts have been used in oral hygiene products for many years all over the world (Gupta et al, 2014b,c). Several conventional anti-plaque agents are available on the market, but with the rise in resistance to antibiotics, there is considerable interest in the development of herbal alternatives for the control of infection (Gupta et al, 2013). A number of clinical studies have shown the effects of using mouthwashes extracted from herbs such as Myrtus communis (Hedayati et al, 2013), Quercus infectoria (Vermani and Prabhat, 2009) Occimum sanctum (Gupta et al, 2014d), Triphala (Chainani et al, 2014), Aloe vera (Gupta et al, 2014; Karim et al, 2014) and Capparis spinosa (Al-Bayaty et al, 2010) in the prevention of dental plaque accumulation and subsequent gingival inflammation. Medicinal plants used to combat diseases have been an integral part of human societies from the dawn of civilisation. Terminalia chebula Retz. (Fam. Combretaceae) is called the ‘King of Medicine’ in Tibet and is always at the top of the list of ‘Ayurvedic Materia Medica’ because of its extraordinary healing power (Nayak et al, 2010). The whole plant possesses high medicinal value and is traditionally used for the treatment of various ailments, such as asthma, sore throat, vomiting, hiccough, diarrhoea, dysentery, bleeding haemorrhoids, ulcers, gout, heart and bladder diseases. The plant has been demonstrated to possess multiple pharmacological and medicinal properties, such as antioxidant, antimicrobial, antidiabetic, hepatoprotective, anti-inflammatory, antimutagenic, antiproliferative, radioprotective, cardioprotective, antiarthritic and anticaries activity, as well as promoting gastrointestinal motility and wound healing. On examining the list of plants recommended for a particular dental therapeutic purpose, it is evident that the ripe fruit of Terminalia chebula is valuable in the prevention and treatment of several diseases of the mouth, such as dental
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caries, spongy and bleeding gums, gingivitis and stomatitis (Kathirvel and Sujatha, 2012). This study was hence planned with the objective of clinically evaluating the efficacy of Terminalia chebula in preventing plaque accumulation and gingival inflammation. It was also compared with a commercially available chlorhexidine 0.2% (CHX) mouthwash and distilled water (placebo).
MATERIALS AND METHODS In this placebo-controlled, double-blind randomised control trial, three groups were studied in parallel at the Department of Public Health Dentistry. The volunteer participants were undergraduate students of the Teerthankar Mahaveer Dental College and Research Centre. The study protocol was approved by the Institutional Review Board (IRB) of Teerthankar Mahaveer University and all subjects signed an IRB-approved consent form. A pilot study was done on 5 patients in each group to check the feasibility of the study; those results are not included in the present study.
Preparation of extract The ripe fruit (400 g) was suspended in 10 times its quantity of sterile distilled water in a round-bottomed flask and kept at 4°C for 72 h. The aqueous extract was decanted, clarified by filtration through a muslin cloth and evaporated in a porcelain dish at 40°C, which resulted in the dried extract. The extract was suspended in polyethylene glycol 400 (20% v:v) and sterile distilled water to yield a final concentration of 30% w:v. The concentrated extract was diluted with sterile distilled water to produce a mouthrinse concentration of 10% (w:v). As a flavouring agent, 0.05% spearmint oil was added.
Inclusion and exclusion criteria Students with no history of any dental treatment, antibiotic or anti-inflammatory drug therapy for the past 3 months were included in the study. Students with any of history systemic diseases or conditions, fibrotic gingival enlargement and smoking were excluded from the study. Participants with good general health, a baseline plaque score greater than 1.5 and a baseline DMFT index of 3 to 5 were included in the study. Those volunteers who had used
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antibiotics or mouthwash for 5 consecutive days or corticosteroids in the past 30 days were excluded from the study. Those subjects who had a history of sensitivity to any mouthwash or used removable prostheses or an orthodontic appliance were excluded from the study. Also, those who had undergone professional measures to remove plaque and calculus in the past 15 days as well as those who did not give consent for the clinical trial were excluded.
Sample size and randomisation All the undergraduate dental students of Teerthankar Mahaveer Dental College and Research Centre were subjected to clinical examination, and a sampling frame (n = 237) was prepared of those who fulfilled the inclusion and exclusion criteria. A sample size of 90 was arrived at by using NMaster Statistical Software (Department of Biostatistics, CMC; Vellore, India). A total of 90 volunteers were randomly allocated into the three study groups through computer-generated random numbers. Random allocation of mouthrinses using the lottery method was done. Individuals were identified by code numbers throughout the study. This clinical trial was conducted according to ADA guidelines 1997, Adjunctive Dental Therapies (Council on Scientific Affairs, 1997). None of the eligible subjects refused to participate in the study. • Group 1 (n = 30) was given 10% Terminalia chebula mouthwash and instructed to use 10 ml twice a day for 30 days. • Group 2 (n = 30) was given 0.2% CHX and instructed to use 10 ml twice a day for 30 days. • Group 3 (n = 30) was the placebo control group and distilled water was given as the mouthwash. All three solutions were made the same colour with the help of the pharmacy department, kept in coded containers and decoded later. Students were instructed to rinse their mouth for 60 s with 10 ml of mouthwash twice daily without subsequent rinsing with water, once after breakfast and once after lunch, for 30 days. Data were collected three times in 30 days for assessing plaque and gingivitis. Clinical measurements for plaque and gingivitis were taken at baseline (prior to the study), 15 days and at the end of the study (4 weeks) using a mouth mirror, explorer, disclosing agent, periodontal probe and tweezers, and were recorded on chart. Study subjects, the investigators and assistants involved
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in the trial were masked with respect to the treatment. During the 30 days of the trial, the subjects continued to exercise their regular non-supervised, self-performed plaque control measures. No oral prophylaxis was done before the start of the study. A single examiner trained and calibrated to record the plaque and gingival scores recorded the findings at all three intervals. Intra-examiner reliability was assessed within an interval of 60 min. Using kappa statistics, intra-examiner reliability was 0.78 for the gingival index and 0.82 for the plaque index. The recorder was blinded to the type of the mouthwash used by participants. None of the parameters – gender, smoking status, level of education, monthly family income, number of teeth present, plaque index, gingival index and gingival bleeding index – were not significantly different between the groups at baseline (all p > 0.1).
Plaque and gingivitis analysis Supragingival plaque was scored according to the Turesky modification of the Quigley-Hein plaque index (Turesky et al, 1970). Scoring of gingival inflammation (gingivitis) was done using the Löe and Silness (1963) gingival index.
Statistical analysis The data were analysed using SPSS version 17. ANOVA was used to analyse the reduction in plaque and gingivitis in the three groups, as well as to assess the intra- and inter-group variations for plaque and gingivitis. This was followed by the post-hoc LSD test to obtain multiple comparisons. A p-value of 0.05 was taken to be significant.
RESULTS All participants in all study groups completed the study. Descriptive baseline statistics are presented in Table 1. The mean ± SD plaque and gingival scores for the Terminalia chebula, CHX and placebo groups are presented in Table 2. ANOVA showed a signifi cant progressive decrease in the plaque and gingivitis scores in both the Terminalia chebula and CHX groups at 15 and 30 days (p < 0.05) (Table 3). The greatest decease was seen in the CHX group, but compared to the Terminalia chebula group, the dif-
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Table 1 Baseline background of the subjects Group 1 (Terminalia chebula)
Group 2 (CHX)
Group 3 (Placebo)
Total number of participants
30
30
30
Age (mean 21.75 years; range 18–27 years)
22.16
21.71
22.13
Frequency of brushing: once daily
22
20
24
Frequency of brushing: twice daily
8
10
6
Other oral hygiene aids used
None
None
None
Rinsing habit
None
None
None
DMFT (mean = 4.5)
4.7
4.5
4.0
Table 2 Plaque and gingivitis score at baseline and after 15 and 30 days Group 1
Group 2
Group 3
Baseline
15th day
30th day
Baseline
15th day
30th day
Baseline
15th day
30th day
Mean
3.00
2.81
2.59
2.89
2.63
2.38
2.98
3.19
3.22
Standard deviation
0.44
0.44
0.46
0.54
0.57
0.57
0.58
0.56
0.56
Range
1.91
1.91
1.91
2.29
2.33
2.33
2.76
2.69
2.69
Mean
2.33
1.70
1.45
2.36
1.66
1.31
2.38
2.40
2.42
Standard deviation
0.43
0.36
0.36
0.45
0.41
0.40
0.49
0.49
0.49
Range
1.00
1.10
1.10
1.00
1.20
1.06
1.00
1.00
1.00
Plaque index
Gingival index
ference was not statistically significant. Rinsing with distilled water (group 3, control) was associated with increased plaque scores. The post-hoc LSD showed that the difference in the decrease in plaque (p = 0.592 at 15 days and p = 1.096 at 30 days; Table 4) and gingivitis (p = 0.837 for 15 days and p = 0.909 for 30 days; Table 5) between Terminalia chebula and CHX groups was not statistically significant. However, the difference between Terminalia chebula and the control group and CHX and the control group was significant (p < 0.05). The data show that there was no significant difference between the Terminalia chebula-based mouthrinse and CHX for any clinical parameters throughout the study.
DISCUSSION This study was conducted on volunteer undergraduate dental students in the Department of Public Health Dentistry, Teerthanker Mahaveer Dental
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College and Research Centre, Moradabad, India over a period of 30 days. Our data show that a mouthrinse based on Terminalia chebula is equally effective in reducing dental plaque and gingivitis as chlorhexidine. In terms of study design, a double-blind controlled clinical trial was chosen, in keeping with the proposal by Overholser Jr. (1988) that clinical studies to evaluate the effectiveness of antimicrobial mouthrinses should be double blind. The undergraduate student volunteers did not discontinue their routine oral hygiene practices during the study. This is similar to the study design used by Axelsson and Lindhe (1987) in a 6-week trial where the subjects continued to exercise their regular non-supervised, self-performed plaque control measures. In the present study, participants were instructed to rinse their mouth with 10 ml of solution for a period of 1 min after lunch and then were told not to rinse their mouth with water or drink anything for half an hour. A similar amount and du-
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Table 3 ANOVA of the three study groups Sum of Squares
Df
Mean Square
F
Sig.
Plaque, baseline
Between groups Within groups
8.170 22.917
2 78
3.761 0.371
11.198
0.681
Plaque, 15 days
Between groups Within groups
2.709 21.190
2 78
1.371 0.319
6.078
0.004
Plaque, 30 days
Between groups Within groups
2.917 22.191
2 78
1.017 0.337
2.009
0.002
Gingivitis, baseline
Between groups Within groups
1.717 14.113
2 78
0.607 0.597
0.871
0.218
Gingivitis, 15 days
Between groups Within groups
3.981 21.194
2 78
3.045 0.307
22.891
0.002
Gingivitis, 30 days
Between groups Within groups
2.819 22.173
2 78
9.711 0.214
50.107
0.017
Table 4 Post-hoc LSD test for multiple comparisons, plaque 95% Confidence interval Variable
Plaque, baseline
(I) Group
(J) Group
Std. Error
Sig.
Lower limit
Upper limit
T. chebula
CHX Placebo T. chebula Placebo T. chebula CHX
0.1890 0.1890 0.1890 0.1890 0.1890 0.1890
0.598 0.312 0.598 0.408 0.312 0.404
-0.012 0.521 -.625 .274 -1.112 -0.791
0.625 1.112 0.012 .791 -0.521 -0.274
CHX Placebo T. chebula Placebo T. chebula CHX
0.1512 0.1512 0.1512 0.1512 0.1512 0.1512
0.592 0.021 0.592 0.029 0.021 0.029
0.082 0.219 -0.721 -0.273 -0.972 -0.479
0.721 0.972 -0.082 0.479 -0.219 0.273
CHX Placebo T. chebula Placebo T. chebula CHX
0.1596 0.1596 0.1596 0.1596 0.1596 0.1596
1.096 0.029 1.096 0.020 0.029 0.020
0.081 -0.162 -0.764 -0.881 -0.481 -0.079
0.764 0.481 -0.081 0.079 0.162 0.811
CHX Placebo T. chebula
Plaque, 15 days
CHX Placebo T. chebula
Plaque, 30 days
CHX Placebo
(I) and (J) designations according to post-hoc analysis by SPSS. The mean difference is significant at the 0.05 level.
ration of mouthwash administration was followed in a study conducted by Gupta et al (2014d). The CHX preparation used in this study did not contain alcohol. Leyes et al (2002) stated that the alcohol-free rinse was as effective as one containing alcohol in controlling plaque and reducing gingival inflammation. CHX gluconate has a long history in dental medicine. Unfortunately, studies have shown that these positive effects are accompanied by side-effects, the most disturbing being extrinsic tooth staining and others such as unpleasant taste and burning sensation (Venkatesh Babu et al, 2011). Menendez et al (2005) found that a lower
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concentration of chlorhexidine (0.12%) may not be sufficiently effective compared with other concentrations, i.e. 0.2%. Hence, in this study, a concentration of 0.2% was used. T. chebula is an important medicinal plant in Indian traditional medicine and it is the most frequently used herb in Ayurveda. The antibacterial activity of T. chebula extracts against several bacterial strains has been reported (Chattopadhyay et al, 2007; Bag et al, 2009). It is effective in inhibiting Helicobactor pylori (Zaidi et al, 2012), Xanthomonas campestris pv. citri (Cheema et al, 2013) and Salmonella typhi (Gupta et al, 2013). It pos-
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Table 5 Post-hoc LSD test for multiple comparisons, gingivitis 95% Confidence interval Dependent variable
Group
(I)
Mean difference(I-J)
Std. Error
Sig.
Lower limit
Upper limit
CHX
-0.1296
0.12692
0.036
-0.3823
0.1231
Placebo
-0.1667
0.12692
0.042
-0.4193
0.0860
T. chebula
0.1296
0.12692
0.036
-0.1231
0.3823
Placebo
-0.0370
0.12692
0.032
-0.2897
0.2156
T. chebula
0.1667
0.12692
0.042
-0.0860
0.4193
CHX
0.0370
0.12692
0.032
-0.2156
0.2897
CHX
-0.1252
0.11768
0.083
-0.3595
0.1091
Placebo
-0.7981
0.11768
0.030
-1.0324
-0.5639
T. chebula
0.1252
0.11768
0.083
-0.1091
0.3595
Placebo
-0.6730
0.11768
0.020
-0.9072
-0.4387
T. chebula
0.7981
0.11768
0.030
0.5639
1.0324
CHX
0.6730
0.11768
0.020
0.4387
0.9072
CHX
-0.0837
0.11685
0.102
-0.3163
0.1489
Placebo
-1.0481
0.11685
0.020
-1.2808
-0.8155
T. chebula
0.0837
0.11685
0.102
-0.1489
0.3163
Placebo
-0.9644
0.11685
0.010
-1.1971
-0.7318
T. chebula
1.0481
0.11685
0.020
0.8155
1.2808
CHX
0.9644
0.11685
0.010
0.7318
1.1971
Group
(J)
T. chebula
Gingivitis, baseline
CHX
Placebo
T. chebula
Gingivitis (15 days)
CHX
Placebo
T. chebula
Gingivitis (30 days)
CHX
Placebo (I), (J)
Designations according to post-hoc analysis by SPSS. The mean difference is significant at the 0.05 level.
sesses antiviral activity against herpes simplex virus type-1 (HSV-1), human immunodeficiency virus-1 (HIV-1) and Cytomegalovirus (Gupta et al, 2013). Terminalia chebula contains almost 30% tannins, which are a group of polymeric phenolic substances. Terminalia chebula extract, with tannin as its active compound, is well recognised for its anticaries and anti-microbial activity as well as its astringent property. Some studies have reported that tannic acid is bacteriostatic or bactericidal to some Gram-negative and Gram-positive pathogens (Iqbal et al, 1998). In group 3, where distilled water was used as the mouthrinse, plaque was found to increase as compared to the baseline score. In the present study, there was no significant difference between CHX and Terminalia chebula mouthwash in terms of plaque and gingivitis scores. Review of the available literature has revealed that no studies have been conducted to assess the effect of Terminalia chebula on plaque and gingivitis,
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although a few studies have assessed the effect of Terminalia chebula on salivary pH and as an anticaries agent. Jagtap and Karkera (1999) analysed the effect of various concentrations of the Terminalia chebula extract ranging from 2% to 30% and found that a 10% concentration of the extract was optimum; thus, in the present study, a concentration of 10% was used. The results of 10% Terminalia chebula extract mouth rinse on plaque and gingivitis could not be compared with other studies, as no other studies on this exist. This makes the present study unique. However, some authors (Bag et al, 2013) suggest that Terminalia chebula possesses other remarkable properties for general and oral health. In addition, Terminalia chebula extract possesses substantivity, which is an essential prerequisite for an ideal mouthrinse (Jagtap and Karkera 1999).
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CONCLUSIONS Terminalia chebula is one of the most versatile medicinal plants, having a wide spectrum of pharmacological activity. This study showed that Terminalia chebula reduced plaque and gingivitis to an extent equivalent to that of the benchmark control chlorhexidine. T. chebula mouthwash has some advantages over CHX: it is much less expensive than the commercially available chlorhexidine mouthwash, is easily accessible and, being an Ayurvedic product, it has no known side-effects and hence is safe for use over a long period of time. These are encouraging results which clearly favour promotion of Terminalia chebula as a mouthrinse for communities, particularly those belonging to low socioeconomic strata. However, as this is the first attempt to assess the effect of Terminalia chebula on plaque and gingivitis, clinical trials of longer duration with a larger sample size should play a vital role in the commercialisation of Terminalia chebula mouthwash. Researchers need to have a fresh look at the field of herbal medicine, as there may be many such plants which potentially possess as-yet scientifcally untested pharmacological activity. Research in the area of herbal medicine is deemed necessary to provide such evidence.
ACKNOWLEDGEMENTS I am highly thankful to my mentor Dr. D.J Bhaskar and Dr. Mary Suvarna for their blessings and support, and also to all the participants for their cooperation.
REFERENCES 1. Al-Bayaty FH, AI-Koubaisi AH, Ali NAW, Abdulla MA. Effect of mouth wash extracted from Salvadora persica (Miswak) on dental plaque formation: A clinical trial. J Medicin Plants Res 2010;4:1446–1454. 2. Axelsson P, Lindhe J. Efficacy of mouth rinses in inhibiting dental plaque and gingivitis in man. J Clin Periodontol 1987;14:205–212. 3. Bag A, Bhattacharyya SK, Bharati P, Pal NK, Chattopadhyay RR. Evaluation of antibacterial properties of Chebulic myrobalan (fruit of Terminalia chebula Retz.) extracts against methicillin resistant Staphylococcus aureus and trimethoprim-sulphamethoxazole resistant uropathogenic Escherichia coli. Afr J Plant Sci 2009;3:25–29. 4. Botelho MA, Bezerra-Filho JG;Correa LL, Heukelbach J. Effect of a novel essential oil mouthrinse without alcohol on gingivitis: a double-blinded randomized controlled trial. J Appl Oral Sci 2007;15:175–180.
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5. Carounanidy U, Satyanarayanan R, Velmurugan A. Use of an aqueous extract of Terminalia chebula as an anticaries agent: a clinical study. Indian J Dent Res 2007;18:152–156. 6. Chainani SH, Siddana S, Reddy C, Manjunathappa TH, Manjunath M, Rudraswamy S. Antiplaque and antigingivitis efficacy of Triphala and Chlorhexidine mouthrinse among schoolchildren – a cross-over, double-blind, randomised controlled trial. Oral Health Prev Dent 2014;12: 209–215. 7. Chattopadhyay RR, Bhattacharyya SK, Medda C, Chanda S, Datta S, Pal NK. Antibacterial activity of black myrobalan (fruit of Terminalia chebula Retz.) against uropathogen Escherichia coli. Phcog Rev 2007;11:212–215. 8. Cheema ZA, Farooq M, Wahid A. Allelopathy: current trends and future applications. Hamburg: Springer, 2013:203–204. 9. Gupta D, Batra R, Mahajan S, Bhaskar DJ, Jain A, Yadav A et al. Comparative evaluation of the complementary and alternative medicine therapy and conventional therapy use from musculoskeletal disorders management and its association with job satisfaction among dentists of West India. J Tradit Complement Med 2014a;4:263–267. 10. Gupta D, Bhaskar DJ, Gupta RK, Jain A, Yadav P, Dalai DR et al. Is complementary and alternative medicine effective in job satisfaction among dentists with musculoskeletal disorders? A cross sectional study. Medycyna Pracy 2014b;65:317–323. 11. Gupta D, Bhaskar DJ, Gupta RK, Karim B, Jain A, Singh R, et al. A randomized controlled clinical trial of Ocimum sanctum and chlorhexidine mouthwash on dental plaque and gingival inflammation. J Ayurveda Integr Med 2014d;5:109–116. 12. Gupta D, Bhaskar DJ, Gupta RK, Karim B, Kanwar A, Jain A, et al. Use of complementary and alternative medicine for work related musculoskeletal disorders associated with job contentment in dental professionals: Indian outlook. Ethiop J Health Sci 2014c:24;117–124. 13. Gupta D, Bhaskar DJ, Gupta RK. Contemporary and alternative dentistry: Ayurveda in dentistry. Saarbrücken: Lap Lambert Academic Publishing, 2013:28–30. 14. Gupta RK, Gupta D, Bhaskar D, Yadav A, Obaid K, Mishra S. Preliminary antiplaque efficacy of aloe vera mouthwash on 4 day plaque re-growth model: Randomized control trial. Ethiop J Health Sci 2014;24:139–144. 15. Hedayati A, Hengameh K, Bazargani A, Abed M, Emami A. Assessing the antimicrobial effect of the essential oil of Myrtus communis on the clinical isolates of Porphyromonas gingivalis: An in vitro study. Jundishapur J Natural Pharmaceut Prod 2013;8:165–168. 16. Herrera D. Chlorhexidine mouthwash reduces plaque and gingivitis. Evid Based Dent 2013;14:17–18. 17. Iqbal A, Zafar M, Faiz M. Screening of some Indian medicinal plants for their antimicrobial properties. J Ethnopharmacol 1998;62:183–193. 18. Jagtap AG, Karkera SG. Potential of the aqueous extract of Terminalia chebula as an anticaries agent. J Ethnopharmacol 1999;68:299–306. 19. Karim B, Bhaskar D.J, Agali A, Gupta D, Gupta RK, Jain A et al. Effect of Aloe vera mouthwash on periodontal health: triple blind randomized control trial. Oral Health Dent Manag 2014;13:14–19. 20. Kathirvel A, Sujatha V. In vitro assessment of antioxidant and antibacterial properties of Terminalia chebula Retz. leaves. Asian Pacific J Tropic Biomed 2012;2:S788–S795.
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Gupta et al 21. Leyes Borrajo JL, Garcia VL, Lopez CG, Rodriguez-Nunez I, Garcia FM, Gallas TM. Efficacy of chlorhexidine mouthrinses with and without alcohol: A clinical study. J Periodontol 2002;73:317–321. 22. Li F, Menendez A, Michalek SM, Kirk K, Makhiya SK, Childers NK. Comparative analysis of the antibacterial effects of combined mouthrinses on Streptococcus mutans. Oral Microbiol Immunol 2005;20:31–34. 23. Löe H, Silness J. Periodontal disease in pregnancy. I. Prevalence and severity. Acta Odontol Scand 1963;21:533–551. 24. Nayak SS, Ashok Kumar BR, Ankola AV, Hebbal M. The efficacy of Terminalia chebula rinse on Streptococcus mutans count in saliva and its effect on salivary pH. Oral Health Prev Dent 2010;8:55–58. 25. Overholser CD, Jr. Longitudinal clinical studies with antimicrobial mouthrinses. J Clin Periodontol 1988;15:517–519. 26. Petersen PE, Yamamoto T. Improving the oral health of older people: the approach of the WHO Global Oral Health Programme. Community Dent Oral Epidemiol 2005;33:81–92.
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27. Turesky S, Gilmore ND, Glickman I . Reduced plaque formation by the chloromethyl analogue of Victamine C. J Periodontol 1970;41:41–43. 28. Twetman S. Antimicrobials in future caries control. Caries Res 2004;38:223–229. 29. Van Strydonck DA, Slot DE, Van der Velden U, Van der Weijden F. Effect of a chlorhexidine mouthrinse on plaque, gingival inflammation and staining in gingivitis patients: a systematic review. J Clin Periodontol 2012;39:1042– 1055. 30. Venkatesh Babu NS, Vivek DK, Ambika G. Comparative evaluation of chlorhexidine mouthrinse versus cacao bean husk extract mouthrinse as antimicrobial agents in children. Eur Arch Paediatr Dent 2011;12:245–249. 31. Vermani A, Prabhat N. Screening of Quercus infectoria gall extracts as anti-bacterial agents against dental pathogens. Indian J Dent Res 2009;20:337–339. 32. Zaidi SF, Muhammad JS, Shahryar S, Usmanghani K, Gilani AH, Jafri W, Sugiyama T. Anti-inflammatory and cytoprotective effects of selected Pakistani medicinal plants in Helicobacter pylori-infected gastric epithelial cells. J Ethnopharmacol 2012;141:403–410.
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