|Year : 2019 | Volume
| Issue : 4 | Page : 269-274
Comparative evaluation of green tea and chlorhexidine mouthwashes on gingivitis: A randomized controlled trial
Omveer Singh1, Vamsi Krishna Reddy1, Devina Pradhan2, Lokesh Sharma1
1 Department of Public Health Dentistry, Sardar Patel Post Graduate Institute of Dental and Medical Sciences, Lucknow, Uttar Pradesh, India
2 Department of Public Health Dentistry, Rama Dental College Hospital and Research Center, Kanpur, Uttar Pradesh, India
|Date of Submission||20-Dec-2018|
|Date of Decision||13-Jan-2019|
|Date of Acceptance||30-Oct-2019|
|Date of Web Publication||12-Dec-2019|
Dr. Devina Pradhan
Department of Public Health Dentistry, Rama Dental College Hospital and Research Centre, Kanpur, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Background: Green tea (Camellia sinensis) is one of the most popularly consumed beverages worldwide containing a number of bioactive chemicals, and it is particularly rich in flavonoids which include catechin. It is linked to a lower incidence of some pathological conditions including oral cancer, dental caries, stroke, cardiovascular diseases, and obesity. Aim: The aim of the study was to compare and evaluate the effects of commercially available green tea mouthwash with chlorhexidine mouthwash on gingivitis. Materials and Methods: A 3-week, double-blinded study was conducted on thirty nursing students aged between 18 and 25 years. Plaque status was assessed by plaque index (Silness and Loe 1964) and gingival status was assessed by gingival index (Loe and Silness 1963) at the 14th day and at the 21st day. Statistical analysis was done using the Statistical Package for the Social Sciences version 21. The test used was one-way analysis of variance and repeated measures. The level of significance was kept as P < 0.05. Results: There was a reduction in the gingivitis scores of the participants using green tea mouthwash as compared to chlorhexidine mouthwash and distilled water. Statistically significant differences were observed between distilled water and green tea groups (P = 0.04). Conclusion: The present study showed that green tea mouthwash was found to be more effective than the chlorhexidine mouthwash in reducing extensive levels of gingivitis.
Keywords: Chlorhexidine, gingivitis, green tea, mouthwash
|How to cite this article:|
Singh O, Reddy VK, Pradhan D, Sharma L. Comparative evaluation of green tea and chlorhexidine mouthwashes on gingivitis: A randomized controlled trial. J Indian Assoc Public Health Dent 2019;17:269-74
|How to cite this URL:|
Singh O, Reddy VK, Pradhan D, Sharma L. Comparative evaluation of green tea and chlorhexidine mouthwashes on gingivitis: A randomized controlled trial. J Indian Assoc Public Health Dent [serial online] 2019 [cited 2020 Sep 23];17:269-74. Available from: http://www.jiaphd.org/text.asp?2019/17/4/269/272787
| Introduction|| |
Oral cavity is the gateway to general health, and the fact is that if this gateway is diseased/not well, then the general health is also hampered. There are numerous diseases of oral cavity, and one of the most common diseases is gingivitis.
Gingivitis occurs mainly due to plaque accumulation, and factors responsible for plaque formation and propagation are poor dental and oral hygiene. It is an early and reversible disease. In this disease, gums become red, swollen, and bleed easily, while provocation such as touching, brushing, or sometimes even spontaneous dental/gum bleeding happens.
Although chlorhexidine is regarded as the gold standard but it has a substantivity for a period of 10-12 hours. The common side effects of chlorhexidine are discoloration of mouth, increase in tartar formation on the teeth, taste problems such as decreased taste or change in taste, mouth ulcer, white patches or sores inside the mouth or on the lips, swelling of salivary glands, and signs of an allergic reaction which may include difficulty in breathing or swelling of the face, lips, tongue, and throat.
Hence, there is a need for a naturally occurring indigenous and cost-effective oral hygiene aid with similar positive effects and decreased adverse effects.
Green tea (Camellia sinensis) is one of the most popularly consumed beverages worldwide containing a number of bioactive chemicals, and it is particularly rich in flavonoids which include catechins. Catechins present in green tea comprise epigallocatechin gallate (EGCG), epicatechin gallate, epicatechin, and eppigallocatechin.,
Green tea also contains carotenoids; tocopherols; ascorbic acid (Vitamin C); minerals such as Cr, Mn, Se, or Zn; and certain phytochemical compounds., The most abundant polyphenolic compound EGCG is thought to contribute to the beneficial effects of tea.
Tea prepared from C. sinensis is of three types: nonfermented green tea that is panfried or steamed and dried to inactivate its enzymes, fermented black tea, and semi-fermented oolong tea. Green tea with active chemical ingredients possesses diverse pharmacological properties which are linked to lower incidence of some pathological conditions including oral cancer, dental caries, stroke, cardiovascular diseases, and obesity. Green tea (C. sinensis) have marvel native defenses that embrace innumerable oral health benefits. Hence, green tea was used in our study to test its efficacy. The hypothesis formed was that there will be an effect on green tea mouthwash with chlorhexidine mouthwash among the gingivitis patients.
Thus, the aim of the study was to compare and evaluate the effects of commercially available green tea mouthwash with chlorhexidine mouthwash in patients with gingivitis.
| Materials and Methods|| |
The present study was a double-blind, randomized, parallel clinical trial. Ethical clearance No: EC/PHD/921519 was obtained from the institutional ethical committee, and informed consent was obtained from all the study participants. A study protocol and a case sheet containing general information, the format for recording plaque and gingival indices, and subjective and objective symptoms were prepared. The detailed flowchart of the protocol is given in [Figure 1].
|Figure 1: Flow diagram of the study protocol according to consort guidelines (2010)|
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The inclusion criteria for selection of the participants were age between 18 and 25 years, having a minimum of twenty teeth, and having plaque score of 2 according to Silness and Loe index  and gingival score of 2 according to Loe and Silness index.
The exclusion criteria were history of systemic diseases, antibiotic and periodontal therapy in the past 3 months, allergy to test products such as irritation and burning sensation, desquamation of oral mucosa, individuals suffering from destructive periodontal disease, using any other chemotherapeutic antiplaque/antigingivitis products, and having severe malalignment of teeth, orthodontic appliances, fully crowned teeth, and removable partial dentures.
Sample size was calculated using the following formula, and it was on the basis of maximum percentage reduction in gingival index within the follow-up period under the study period in the two study groups using the formula for comparison of proportionate change, by putting proportion change of gingival index as 0.8% and 0.8% in the two study groups and an error ratio (e) of 0.25 was considered to be clinically significant.
Considering 95% confidence level, 90% power of the study, and 10% loss to follow-up, the sample size was calculated to be thirty for each group.
Initially, sixty nursing students who were studying at our institution were approached and screened for the eligibility criteria, but after applying inclusion and exclusion criteria, finally, thirty nursing students were undertaken as the final sample size.
The examination throughout the study was carried out by a single investigator who was trained and calibrated. Kappa coefficient value for intra-examiner reproducibility was 0.86.
The indices used for recording plaque were plaque index given by Silness and Loe and gingival index given by Loe and Silness.,
All the participants' baseline scores of plaque and gingivitis were recorded. All the participants were instructed for the modified Bass technique of toothbrushing and then randomly allocated using lottery method into three groups (ten in each group):
- Group A – 0.2% chlorhexidine gluconate mouthwash (experimental group) (PerioGard®)
- Group B – Green tea mouthwash (experimental group) Colgate Plax®
- Group C – Distilled water (control group or placebo)
Each participant was identified by a code.
All the mouthwashes were dispensed in identically looking plastic bottles measuring 110 ml and were coded as A, B, and C. The mouthwashes (110 ml) were then distributed among the participants during each successive visit. Group allocation and dispensing of the mouthwashes were independently performed by a separate investigator. In the study, both the investigator and the participants were blind.
Written instructions regarding the use of the mouthwash were provided to the participants. All the participants were instructed to rinse twice daily with 5 ml of the allocated mouthwash (undiluted) for 30 s, after 30 min of toothbrushing. Subsequent rinsing with water was not allowed before 20 min of mouthwash use. They were provided with measuring cups with 5 ml marking in order to use the correct volume of mouthwash. They were also asked to brush their teeth with a soft nylon toothbrush and a nontherapeutic, low-abrasive dentifrice. The mouth rinsing was performed at home. To check for compliance, the participants were asked to note the times of day when they used mouthwash. The quantity of mouthwash given to the participants was precalculated before giving to the participants at every visit.
Participants were instructed to visit back at the 14th and 21st days [Figure 1] for subjective examination. At the 14th and 21st days, they were asked to bring their bottles and the remaining volume of water was calculated.
At both the recall visits, plaque and gingival indices were recorded., Any side effects with the use of the given products either subjective (such as taste acceptability, burning sensation, dryness, or soreness of mouth) or objective (such as staining of teeth, staining of tongue, ulcer formation, and allergy) were also recorded. The participants were instructed to follow the routine plaque control measures as before including the use of mouthwash.
After the collection of data, it was analyzed using SPSS version 21 (IBM Corp. Released 2012. IBM SPSS Statistics for Windows, Version 21.0, IBM Corp., Armonk, NY, India). Intergroup comparison of plaque and gingivitis scores was done using one-way analysis of variance (ANOVA) test and repeated measures. The level of significance was kept as P < 0.005, and the normality of the data was tested by Shapiro–Wilk test.
| Results|| |
In Groups I, II, and III, the mean age of the participants was 22.3, 21.6, and 20.4 years significantly. There was no statistically significant difference observed (P = 0.067) [Table 1].
Among the gender, female participants were more in all the three groups (22, 20, and 18, respectively). However, no statistical significance was observed (P = 0.866) [Table 2].
The plaque index scores in the three groups were compared using one-way ANOVA at each time interval. There was no statistically significant difference at baseline. At the first and second intervals, there was an overall statistically significant difference between plaque index scores between the three groups (P < 0.05). The plaque scores at the second recall were lowest for the green tea group, followed by chlorhexidine and distilled water groups [Table 3].
|Table 3: Comparison of plaque index among three groups over three timelines|
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The plaque index scores changed from baseline among the groups over timeline, and it was found to be significant at the first and second recalls in case of chlorhexidine and green tea (P < 0.05) but insignificant (P = 0.130) at the first recall in case of distilled water [Table 4].
|Table 4: Intragroup comparison of plaque index change from baseline among the groups over timelines|
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The gingival index scores in the three groups were compared using one-way ANOVA at each time interval. There was no statistically significant difference at baseline. At the first and second intervals, there was an overall statistically significant difference between bleeding index scores between the three groups (P < 0.05). The bleeding scores at the second recall were lowest for the green tea group, followed by chlorhexidine and distilled water groups. Statistically significant differences were observed between the distilled water with green tea group and the distilled water with chlorhexidine group [Table 5].
|Table 5: Comparison of gingival index among three groups over three timelines|
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The gingival index scores change from baseline among the groups over timeline, and it was found to be significant at the first and second recalls in case of chlorhexidine and green tea (P < 0.05) but insignificant (P > 0.050) at the first and second recalls in case of distilled water [Table 6].
|Table 6: Intragroup (post hoc) comparison of bleeding index change from baseline among the groups over timeline|
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| Discussion|| |
Plant extracts have been widely used in topical and oral applications for disease treatment. The phenolic compound in green tea may block the growth of bacteria responsible for tooth cavity and plaque formation.,
Dental plaque is the major etiological factor responsible for periodontal disease. Plaque control is a critical component of dental practice, permitting long-term success of periodontal and dental care. There is a growing interest throughout the oral health-care profession in therapeutic agents that complement and enhance the mechanical removal of biofilms in the oral cavity.
Various chemical methods of reducing plaque, such as mouth rinses, are used, as they can provide significant benefits to patients who cannot maintain adequate mechanical plaque control. Most of the mouth rinses, which contain modern chemicals such as chlorhexidine, have undesirable side effects, such as staining of teeth and taste alteration.
Hence, there has been increased interest in plants with antibacterial and anti-inflammatory activities. The numerous side effects associated with these substances have limited their long-term use. Of the numerous herbal extracts, green tea (C. sinensis) have numerous medicinal benefits, mainly due to their antibacterial and antioxidant properties.,
With regard to this, the present study evaluated the effect of mouthwash containing green tea on chronic generalized plaque-induced gingivitis, in comparison with 0.2% chlorhexidine.
The percentage reduction of plaque and gingival indices in the green tea group was 0.8% and 0.7%, respectively, from baseline to the 21st day which is similar to the study by Priya et al. in which the percentage reduction of plaque and gingival indices was 0.8% and 0.7%, respectively.
The percentage reduction of plaque and gingival indices in the chlorhexidine group was 0.8%, 0.6%, respectively, from the baseline to the 21st day which is similar to the study by Biswas et al. in which percentage reduction of gingival index was 0.8% and 0.7% respectively.
In the present study, a statistically significant decrease in plaque index scores was observed in the chlorhexidine and green tea groups, which is similar to the study by Priya et al. which also showed a significant difference in gingival index scores in both the groups.
Furthermore, in the present study, a statistically significant decrease in gingival index scores was observed in the chlorhexidine and green tea groups, which is similar to the study by Priya et al. which also showed a significant difference in gingival index scores in both the groups  and in contrast with the study by Biswas et al. which showed statistically nonsignificant difference in gingival index scores in both the groups.
This probably happened due to decreased collagenolytic activity and inhibitory effect on periodontal pathogens.
In the present study, the difference between the green tea and chlorhexidine groups in relation to plaque index showed better results in the green tea group, followed by chlorhexidine group, which is similar to the study by Biswas et al. which showed better results in the green tea group, followed by chlorhexidine group.
The difference between the green tea and chlorhexidine groups in the present study in relation to plaque index was nonsignificant, which is in contrast with the study by Biswas et al. which showed a significant difference between the green tea and chlorhexidine groups in relation to plaque index.
In the present study, the difference between the green tea and chlorhexidine groups in relation to gingival index showed better results in the green tea group, followed by chlorhexidine group, though it was not statistically significant which is similar to the study by Biswas et al. which showed better results in the green tea group, followed by chlorhexidine group, and this difference was also not significant.
Chlorhexidine till date is the proven most effective antiplaque agent. Its efficacy can be attributed to its bacteriostatic and bactericidal properties. However, its long-term use is limited due to local side effects including extrinsic tooth and tongue brown staining, taste disturbance, enhanced supragingival calculus formation, and desquamation of the oral mucosa. As compared to this, herbal (green tea) mouthwash due to its natural ingredients has no reported side effects and can serve as a good alternative to patients who wish to avoid alcohol (e.g., xerostomia patients), sugar (e.g., diabetics), any artificial preservatives, and colors in their mouth rinses.,
The study has several limitations. A crossover design with wash off point could have been more authenticative study design as it estimates the bias of variable host response. Furthermore, a longer period could through light on the long-term advantages and disadvantages of the green tea mouthwash. Further research to establish the level of substantivity, plaque inhibition, safety, and microbial parameters is necessary before this product finds a place among the other agents for daily plaque removal. The finding of the present study can be applied to other clinical settings and public health programs.
| Conclusion|| |
The present study showed that green tea mouthwash was found to be more effective than the chlorhexidine mouthwash, in order to reduce the extensive levels of gingivitis. Both 0.2% chlorhexidine gluconate and green tea mouthwashes can be effectively used as an adjunct to mechanical plaque control in the prevention of plaque and gingivitis. However, owing to the side effects reported due to the use of chlorhexidine mouthwash and biocompatibility and well acceptance of green tea mouthwash by the participants, it can be effectively used as an alternative to chlorhexidine mouthwash.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Singh B, Dressings R. Gingivitis – A silent disease. J Dent Med Sci 2013;6:30-3.
Prasanna SG, Lakshmanan R. Characteristics, uses and side effects of chlorhexidine – A review. J Dent Med Sci 2016;15:50-9.
Biswas S, Rithesh K, Savita S, Shivaprasad BM. Comparative evaluation of the effect of green tea, listerine and chlorhexidine mouth washes in gingivitis patients: A randomized controlled trial. Sch J Dent Sci 2015;2:104-12.
Kudva P, Tabasum ST, Shekhawat NK. Effect of green tea catechin, a local drug delivery system as an adjunct to scaling and root planing in chronic periodontitis patients: A clinicomicrobiological study. J Indian Soc Periodontol 2011;15:39-45.
] [Full text]
Mageed MJ, Saliem SS. Antibacterial effects of green tea extracts on aggregatibacter actinomycetemcomitans (in-vitro
study). J Baghdad Coll Dent 2015;27:102-8.
Silness J, Loe H. Periodontal disease in pregnancy. II. Correlation between oral hygiene and periodontal condtion. Acta Odontol Scand 1964;22:121-35.
Loe H, Silness J. Periodontal disease in pregnancy. Acta Odontol Scand 1963;21:533-51.
Indrayan A. Basic methods of medical research. 2nd
ed. Indian J Community Med 2008;33:308. [Full text]
Sargolzaie1 N, Rajabi O, Arab H, Esmaele H, Ehteshamfar A. Comparative evaluation of green tea-aloe vera mouthwash and chlorhexidine 0.2% on gingival indices (A randomized clinical trial). J Dent Mater Tech 2016;5:31-5.
Moghbel A, Farjzadeh A, Aghel N, Agheli H, Raisi N. The effect of green tea on prevention of mouth bacterial infection, halitosis, and plaque formation on teeth. Iran J Toxicol 2011;5:502-15.
Okamoto M, Sugimoto A, Leung KP, Nakayama K, Kamaguchi A, Maeda N. Inhibitory effect of green tea catechins on cysteine proteinases in Porphyromonas gingivalis
. Oral Microbiol Immunol 2004;19:118-20.
Kushiyama M, Shimazaki Y, Murakami M, Yamashita Y. Relationship between intake of green tea and periodontal disease. J Periodontol 2009;80:372-7.
Rassameemasmaung S, Phusudsawang P, Sangalungkarn V. Effect of green tea mouthwash on oral malodor. ISRN Prev Med 2013;2013:1-6.
Kondreddi S, Rao MV, Kastala VH. Crucumin and camellia: Novel indigenous armours-A pilot study to evaluate the efficacy of 5% green tea mouthwash in comparison with 0.1% turmeric mouthwash as an adjunct to oral prophylaxis in treatment of plaque induced gingivitis Int J Recent Sci Res 2016;7:13406-09.
Priya BM, Anitha V, Shanmugam M, Ashwath B, Sylva SD, Vigneshwari SK. Efficacy of chlorhexidine and green tea mouthwashes in the management of dental plaque-induced gingivitis: A comparative clinical study. Contemp Clin Dent 2015;6:505-9.
] [Full text]
Mathur S, Mathur T, Srivastava R, Khatri R. Chlorhexidine: The gold standard in chemical plaque control. Natl J Physiol Pharm Pharmacol 2011;1:45-50.
Vaish S, Ahuja S, Dodwad V, Prakash H. Comparative evaluation of 0.2% chlorhexidine versus herbal oral mouthrinse on plaque induced gingivitis. J Indian Assoc Public Health Dent 2012;10:55-62. [Full text]
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;15:349-52.
] [Full text]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]