|Year : 2020 | Volume
| Issue : 2 | Page : 111-117
Comparative evaluation of indigenous herbal mouthwash with 0.2% chlorhexidine gluconate mouthwash in prevention of plaque and gingivitis: A clinico-microbiological study
Vrushali Ramdas Khobragade1, Prashanth Yachrappa Vishwakarma2, Arun Suresh Dodamani2, Vardhaman Mulchand Jain2, Gaurao Vasantrao Mali2, Minal Madhukar Kshirsagar2
1 Department of Public Health Dentistry, VYWS Dental College, Amravati, Maharashtra, India
2 Department of Public Health Dentistry, ACPM Dental College, Dhule, Maharashtra, India
|Date of Submission||19-Dec-2019|
|Date of Decision||02-May-2020|
|Date of Acceptance||04-May-2020|
|Date of Web Publication||24-Jun-2020|
Dr. Prashanth Yachrappa Vishwakarma
Department of Public Health Dentistry, ACPM Dental College, Dhule, Maharashtra
Source of Support: None, Conflict of Interest: None
Background: Plaque control measures are important to maintain proper oral hygiene. Indigenous medicines can be alternatives considered with minimal or no side effects to treat oral diseases. Aim: To determine and compare the antibacterial efficacy of indigenous herbal mouthwash with 0.2% chlorhexidine gluconate. Materials and Methods: The present study was conducted in two parts, and it was registered for the Clinical Trials Registry-India. The first part consisted of in vitro evaluation in which disc diffusion and minimum inhibitory concentration (MIC) methods were used. In the second part, a clinical trial was conducted among 30 participants of 18–40 years' age group to evaluate and compare the antibacterial efficacy of indigenous herbal mouthwash with 0.2% chlorhexidine gluconate. Plaque and gingival health assessments were carried out using the plaque index and gingival index on the 7th day, 14th day, and 21st day. All statistical procedures were performed using the Statistical Package for the Social Sciences 20.0 software (IBM, Armonk, NY, USA). It was assessed at 5% level of significance, i.e., P < 0.05 was considered as statistically significant. Results were statistically analyzed with unpaired t-test for pairwise intergroup multiple comparisons, on the 21st day, when plaque and gingival health were compared using plaque and gingival indices (P < 0.05). Results: Indigenous herbal mouthwash was seen to be sensitive at 12.5 mg/ml, and the zone of inhibition was highest against Prevotella intermedia (23 mm). With 0.2% chlorhexidine gluconate, the zone of inhibition was highest for Porphyromonas gingivalis and Prevotella intermedia (25 mm each) and MIC was seen to be 12.5 mg/ml for Bacteroides forsythus and 0.2 mg/ml for Streptococcus mutans and Lactobacilli by broth technique. In vivo examination showed a decrease in mean scores of plaque index and gingival index with chlorhexidine and indigenous herbal mouthwash from baseline to 21 days. Conclusion: From the present study, it was seen that there was a statistically significant reduction in both clinical and microbiological parameters with the use of an indigenous herbal mouthwash as well as 0.2% chlorhexidine gluconate. However, chlorhexidine mouthwash was statistically efficacious at the 21st day in controlling plaque and gingivitis with potent antimicrobial activity.
Keywords: Chlorhexidine gluconate, gingivitis, herbal mouthwash, oral health
|How to cite this article:|
Khobragade VR, Vishwakarma PY, Dodamani AS, Jain VM, Mali GV, Kshirsagar MM. Comparative evaluation of indigenous herbal mouthwash with 0.2% chlorhexidine gluconate mouthwash in prevention of plaque and gingivitis: A clinico-microbiological study. J Indian Assoc Public Health Dent 2020;18:111-7
|How to cite this URL:|
Khobragade VR, Vishwakarma PY, Dodamani AS, Jain VM, Mali GV, Kshirsagar MM. Comparative evaluation of indigenous herbal mouthwash with 0.2% chlorhexidine gluconate mouthwash in prevention of plaque and gingivitis: A clinico-microbiological study. J Indian Assoc Public Health Dent [serial online] 2020 [cited 2021 May 7];18:111-7. Available from: https://www.jiaphd.org/text.asp?2020/18/2/111/287631
| Introduction|| |
Human beings are the creations of nature. Nature provides us everything what is needed for our survival. Although herbs had been known for their medicinal, flavoring, and aromatic qualities for centuries, the synthetic products of the modern age surpassed their importance for a while. However, the blind dependence on synthetics is been decreased to the great extent, and people are returning to the naturals with the hope of safety and security. Hence, it is time to promote them globally.
Out of numerous oral diseases, dental caries and periodontal diseases are seen more prevalent among population with a common etiology, i.e., dental plaque. Dental plaque is a biofilm with layers of microorganisms contained in a matrix that forms on oral surfaces. Thus, plaque control should be an indispensable part of the daily chores of every individual as the onset of dental diseases can be primarily prevented by regular and meticulous plaque removal. Toothbrushing, when accomplished properly, results in effective plaque control. However, whenever it is accompanied by chemical plaque control measures, it gives a synergistic effect. Therefore, adjunctive chemical plaque control methods such as the use of mouthwash have been suggested as an additional therapeutic strategy to augment but definitely not to replace mechanical plaque control. Mouthwash supplements routine mechanical oral hygiene procedures in controlling supragingival plaque formation.
Ideally, it is required that any antimicrobial/antiseptic agent used should be able to modify the oral environment by being specifically effective against pathogens without altering the normal flora. There are several types of mouthwash available in the market today worldwide. Many of these mouthwashes have not been tested adequately, and the information is lacking as to when and how to use these agents for maximum benefit. Chlorhexidine digluconate has been the agent of choice as an antiplaque agent when compared to others and is considered as the gold standard. However, due to its side effects, its acceptance by patients can be limited, especially when a longer period of use is recommended.
The global need for an alternative prevention and treatment options and products for oral diseases that are safe, effective, and economical comes from the rise in disease incidence (particularly in developing countries), increased resistance by pathogenic bacteria to currently used antibiotics and chemotherapeutics, opportunistic infections in immunocompromised individuals, and financial considerations in developing countries. Several chemical antiplaque agents are available commercially, and they can be delivered in the form of mouthwash, dentifrices, chewing gums, and gel. However, they have some undesirable side effects such as vomiting, diarrhea, and tooth staining.
Ayurvedic medicinal plants are used in various treatments as there are no or minimal side effects. Several herbal mouthwash and herbal extracts have been testedin vitro andin vivo in search of a suitable adjunct to mechanical therapy for long-term use.,,,,,,, Ayurvedic medicines give a holistic approach toward an entire human being. It can maintain the balance between general and oral health as well as an environment which is in this era necessary for well-being of humans.
In the present study, one such attempt is made considering herbal medicines as an effective adjuvant for improving oral health.
| Materials and Methods|| |
The present study was a clinico-microbiological study. This study was conducted between August 2018 and September 2018.
The present study was conducted in two parts. Under an in vitro evaluation, the mouthwash samples for the present study were previously labeled assigning the letters: A (indigenous herbal mouthwash) and B (0.2% chlorhexidine gluconate). 0.2% chlorhexidine gluconate (Rexidin Indoco Remedies Ltd.) is readily available in market.
The mouthwash has been prepared in the department of Dravyaguna Vigyan (department of pharmacology) at an Ayurveda college. Triphala Kwath is a water decoction made from three fruits, i.e., Amla, Haritaki, and Bibhitaki. Aqueous miswak extract is prepared by breaking miswak twigs into pieces; water is added and heated until one-fourth water remains. Later, the liquid is strained through a Whatman No. 1 filter paper (24 cm) and extract is collected. Similarly, ginger and garlic extracts were also prepared freshly during mouthwash preparation by crushing the pieces, followed by straining through filter paper. Peppermint water is prepared by adding peppermint oil in water. Wintergreen oil (Absolute Fragrances [P] Ltd.) is brought readymade from market. Lemon extract was used to mask the pungent effect of garlic [Table 1].
|Table 1: List of ingredients which constitute an indigenous herbal mouthwash,|
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The culture media used in the present study was brain–heart infusion (BHI) agar for disc diffusion and BHI broth for minimum inhibitory concentration (MIC). Freeze-dried strains of Streptococcus mutans (ATCC, 25175), Lactobacilli (ATCC, 53103), Porphyromonas gingivalis (ATCC, 33277), Prevotella intermedia (ATCC, 25611), and Bacteroides forsythus (ATCC, 33521) were obtained from the Institute of Microbial Technology, Chandigarh.
The abovementioned five different strains of organisms were first transferred to BHI agar at room temperature. Inoculated plates were allowed to stand for at least 3 min but no longer than 15 min before making wells. These solutions were aseptically introduced into the wells with the help of sterile micropipette. After 24 h of incubation in incubator at 37°C, agar plates were observed for the zone of inhibition (areas without growth of test organisms).
It was measured as the maximum width from the edge of the well to the periphery of the inhibition zone with the help of Vernier caliper. Themaximum zone of inhibition would determine the inhibition of bacterial growth in an agar plate, so the maximum zone was measured. For disc diffusion, five wells were prepared on a single agar plate.
The MIC was defined as the highest dilution of the agent that inhibited bacterial growth, as determined by lack of turbidity. For the broth dilution assays, test strains were inoculated into tubes containing serial dilutions of antimicrobial agents (i.e., 100, 50, 25, 12.5, 6.25, 3.12, 1.6, 0.8, 0.4, and 0.2 μl/ml) in BHI broth and incubated at 35°C for 48–72 h.
The present in vivo study was conducted at ACPM Dental College, Dhule. The study was registered for the Clinical Trials Registry-India (CTRI/2018/08/015348). Ethical clearance for the study was obtained from the Institutional Ethics Committee (1045/ACPMDC/Dhule). The study was conducted according to CONSORT guidelines (2010). Patients were selected from the Outpatient Department, Department of Public Health Dentistry, after getting a written informed consent. It is a randomized, single-blind, parallel study conducted over a period of 21 days among 30 participants aged between 18 and 40 years who fulfilled the eligibility criteria.
The sample size was calculated using GPower 3.0.10 software, Düsseldorf University, Düsseldorf, Northrhine-Westphalia, Germany. Effect size was derived using data obtained from previous research conducted by Kripal et al.
T-test means difference between two dependent means (matched pairs):
Analysis: A priori: Compute required sample size:
- Individuals who were willing to participate in the present study and gave their written consent for the same
- Individuals belonging to the age group of 18–40 years
- Individuals suffering from mild-moderate gingivitis.
- Individuals suffering from any systemic diseases
- Individuals taking medications since prolonged duration
- Individuals wearing fixed or removable orthodontic appliances or prosthesis
- Individuals having chronic generalized periodontitis or any other oral disease
- Individuals who underwent any periodontal therapy in the last 6 months
- Individuals who were not willing to participate in the present study.
Participants were informed about the purpose and protocol of the present study, and written consent was obtained and randomly divided by block randomization technique into two groups equally as Group A and Group B where Group A included oral prophylaxis along with an indigenous herbal mouthwash and Group B included oral prophylaxis along with the use of chlorhexidine mouthwash (0.2%).
Participants of each group were not aware of the type of mouthwash given to them for use. The mouthwashes were dispensed in an uncolored (amber colored) bottles. At baseline, plaque assessment was carried out using the plaque index (Silness and Loe, 1964) and gingivitis assessment using the gingival index (Loe and Silness, 1963) to record the gingival health status. Gingival and plaque indices were recorded by a single examiner (principal investigator) with the help of #3 Hu-Friedy HD Mouth Mirror, Williams graduated periodontal probe, and Wilkins explorer. After oral prophylaxis of all teeth, oral hygiene instructions were given to all the participants and were distributed with similar toothbrush and toothpaste in an attempt to maintain standardization and improve their oral hygiene. Participants were given a demonstration of the Modified Bass Brushing Technique and asked to follow the same technique. Group A was instructed to rinse with 10 ml undiluted herbal mouthwash for 1 min twice daily after meals for 21 days, and Group B was instructed to rinse with undiluted 10 ml chlorhexidine gluconate for 1 min twice daily after meals uninterruptedly for 21 days. Subsequent follow-up of the patients was done to assess the effect of intervention on gingival health by recording plaque and gingival assessments on the 7th day, 14th day, and 21st day. Participants were asked to report immediately if they felt any discomfort in using the mouthwashes during the course of the present study. No dropouts have been observed during the course of the present study.
Before commencing the study, clinical examination of every patient was carried out by the principal investigator herself. Before the start of the study, the examiner was trained and calibrated at the Department of Public Health Dentistry. The calibration was done on 15 participants, but these participants were not included in the present study.
All statistical procedures were performed using the Statistical Package for the Social Sciences 20.0 software (IBM, Armonk, NY, USA) Unpaired t-test was applied which was assessed at 5% level of significance, i.e., P < 0.05 was considered as statistically significant.
| Results|| |
Results of the present study (in vitro) showed that commercially available 0.2% chlorhexidine gluconate mouthwash and indigenous herbal mouthwash were effective against test organisms. Indigenous herbal mouthwash was seen to be sensitive at 12.5 mg/ml, and the zone of inhibition was highest against P. intermedia (23 mm). With 0.2% chlorhexidine gluconate, the zone of inhibition was highest for P. gingivalis and P. intermedia (25 mm each) and MIC was seen to be 12.5 mg/ml for B. forsythus and 0.2 mg/ml for S. mutans and lactobacilli by broth technique [Table 2], [Table 3] and [Figure 1].
|Table 2: Comparison of indigenous herbal mouthwash and chlorhexidine mouthwash by disc diffusion method|
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|Table 3: Comparison of indigenous herbal mouthwash and 0.2% chlorhexidine mouthwash by minimum inhibitory concentration|
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|Figure 1: Disc diffusion for Prevotella intermedia and Porphyromonas gingivalis. 1 and 3: Disc diffusion for indigenous herbal mouthwash against Prevotella intermedia. 2 and 4: Disc diffusion for 0.2% chlorhexidine gluconate against Porphyromonas gingivalis|
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In vivo comparison of plaque and gingival indices at each interval was done using unpaired t-test (P ≤ 0.05). On the 21st day, when plaque and gingival health were compared using plaque and gingival indices, results were statistically significant [Table 4].
|Table 4: Comparison of plaque index and gingival index in 0.2% chlorhexidine mouthwash and indigenous herbal mouthwash groups at each interval|
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[Graph 1] showed a decrease in mean scores of plaque index and gingival index with chlorhexidine and indigenous herbal mouthwash from baseline to 21 days.
| Discussion|| |
Dental plaque is the primary etiological factor for the mostly occurring oral diseases such as dental caries and periodontal diseases. Mechanical plaque control is the major important tool for the prevention of oral diseases and requires patient cooperation and motivation. Therefore, chemical plaque control agents act as a useful adjuvant for achieving the desired results. Mouthwash has been recommended being a regular adjunct along with mechanical therapy to maintain oral health. Considering the adverse effects of the use of chlorhexidine, its use for long-term therapy has been limited or not actively recommended.,,
There are numerous natural ayurvedic plants which have a great significance in dentistry. Previous literature suggest that herbal/natural product for management of dental ailments has shown favorable results where some of these natural plants have been used for preparation of mouthwashes such as green tea, turmeric, neem, cranberry, Aloe vera, pot marigold, and triphala, and studies conducted have proved to be effective in reducing plaque accumulation and gingival inflammation.,,,,,,
In the present study, an indigenous herbal mouthwash and commercially available 0.2% chlorhexidine gluconate mouthwash were tested against the 5 different organisms. S. mutans and Lactobacilli for assessing the caries status whereas P. gingivalis, P. intermedia, and B. forsythus for gingival and periodontal health assessments.,,
The herbal extracts used in an indigenous herbal mouthwash such as triphala (Phyllanthus emblica, Terminalia chebula, and Terminalia bellirica), wintergreen oil (Gaultheria procumbens), garlic (Allium sativum), miswak aqueous extract (Salvadora persica), ginger (Zingiber officinale), lemon extract (Citrus limon), and peppermint water (Mentha piperita) are known to have antimicrobial activity on some of the common oral pathogens., In another study, the ex vivo effect of the herbal mouthwash has been seen on organisms from supragingival dental plaque in healthy and chronic periodontitis patients., However, in the present study, we aimed to look at the panel of organisms which can effectively reduce both the supra- and subgingival dental plaque.
One of the studies was conducted on chlorhexidine gluconate and turmeric mouthwash which showed that both can be effectively used as an adjunct to mechanical plaque control in the prevention of plaque and gingivitis. Another study was conducted on chlorhexidine and herbal mouthwash where chlorhexidine showed higher levels of antimicrobial action than the herbal mouthwash against bacterial species.
In the present study, an indigenous herbal mouthwash at 75 μl/ml concentration showed 18 mm, 15 mm, 20 mm, 23 mm, and 18 mm zone of inhibitions, respectively, against S. mutans, lactobacilli, P. gingivalis, P. intermedia, B. forsythus and was observed to be sensitive at 12.5 mg/ml, whereas for commercially available 0.2% chlorhexidine gluconate mouthwash, the zone of inhibition was observed highest at 75 μl/ml concentration as 21 mm, 20 mm, 25 mm, 25 mm, and 20 mm, respectively, and MIC was observed to be 12.5 mg/ml for P. gingivalis, P. intermedia, and B. forsythus and 0.2 mg/ml for S. mutans and lactobacilli by broth technique.
These findings reinforce the earlier findings that variation in the media can affect the MIC values of a compound and that MIC values are method dependent. It may be that the constituents of the agar media could have influenced some of the antimicrobial properties of both the mouthwashes. The presence of exogenous proteins in the media or the ability of media components to reduce the antimicrobial activity or the biding of the mouthwash components to protein in the media can influence the antimicrobial efficacy.
For the present study, in order to support the results obtained (in vitro), an in- vivo study has been conducted to assess the effect of the abovementioned mouthwashes on gingival health in two groups. On subsequent follow-up at the 7th, 14th, and 21st days, it was seen that plaque and gingival health status were improved in all the groups.
In the present study, an Indigenous Herbal mouthwash was seen to improve plaque and gingival scores to some extent. Herbal mouthwash was not associated with any discoloration of teeth or unpleasant taste and was effective in reducing plaque accumulation and gingival inflammation unlike chlorhexidine mouthwash. Thus, herbal mouthwash can be effectively used as an alternative to chlorhexidine and can be prescribed for longer duration with no side effects for management of periodontal diseases.
More studies should be conducted on herbal mouthwash by modifying the ingredients, and it should be explored for its cost-benefit and cost-effectiveness on long-term usage to meet the gold standard.
| Conclusion|| |
Herbal mouthwash effectively reduces plaque accumulation and gingivitis.
They are considered to be good alternative over synthetic formulations in current trends of prevention.
The authors would like to thank all the participants who gave their valuable time and consent for the present study and Dr. Akbar Khan (BAMS, PGDEMS, PDCR) for his valuable support in mouthwash preparation and Dr. Mahesh Khairnar (BDS, MDS) for helping in statistical analysis.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4]