|Year : 2021 | Volume
| Issue : 4 | Page : 259-263
Effectiveness of manuka honey and chlorhexidine mouthwash on gingivitis and Streptococcus Mutans count among children: A randomized controlled trial
KS Sruthi, R Yashoda, P Manjunath Puranik
Department of Public Health Dentistry, Government Dental College and Research Institute, Bengaluru, Karnataka, India
|Date of Submission||21-Dec-2020|
|Date of Decision||17-Jul-2021|
|Date of Acceptance||16-Oct-2021|
|Date of Web Publication||15-Dec-2021|
K S Sruthi
Room No: 9, 1st Floor, Department of Public Health Dentistry, Government Dental College and Research Institute, Fort, Bengaluru - 560 002, Karnataka
Source of Support: None, Conflict of Interest: None
Background: Chlorhexidine is considered a gold standard among the chemical plaque control measures. Recently, a search for a natural alternative having similar effectiveness of that of chlorhexidine is gaining importance due to various side effects reported. Honey is a natural product with antibacterial properties that can be used to improve oral health. Manuka honey (MH) is considered superior due to its antibacterial properties. However, studies pertaining to effectiveness of MH and chlorhexidine on oral health are limited. Aim: This study aimed to evaluate the effectiveness of MH and 0.2% chlorhexidine digluconate (CHX) mouthwash on reducing gingivitis and Streptococcus mutans count (SM). Materials and Methods: A randomized controlled trial blinded study was conducted among 12–15 years old children with (Decayed, Missing, Filled Teeth) scores of 1–4, plaque and gingival scores of 1–2 were selected, and an equal number of children (30 each) were randomly allocated to MH and CHX groups. Participants were instructed to rinse 5 ml of MH and 10 ml of CHX twice daily for 14 days. Unstimulated saliva was collected from the children, and plaque and gingival indices were assessed at baseline, 7th day, and 14th day. Unstimulated saliva was subjected to microbiological analysis for SM. Student's t-test and repeated-measures analysis of variance test were applied for inter- and intragroup comparison, respectively. P < 0.05 was considered significant. Results: There was no statistically significant difference in plaque and gingival scores and SM count between the groups at baseline, 7th day, and 14th day. Statistically significant reductions (P < 0.01) in plaque, gingival scores, and SM count were observed in both the groups at 7th and 14th day from baseline. No adverse events were reported during the trial. Conclusion: Effectiveness of MH was comparable with CHX mouthwash in reducing gingivitis and SM count. MH seems to be a promising antimicrobial agent effective in improving gingival health and reducing caries risk.
Keywords: Chlorhexidine, dental plaque, gingivitis, manuka honey, Streptococcus mutans
|How to cite this article:|
Sruthi K S, Yashoda R, Puranik P M. Effectiveness of manuka honey and chlorhexidine mouthwash on gingivitis and Streptococcus Mutans count among children: A randomized controlled trial. J Indian Assoc Public Health Dent 2021;19:259-63
| Introduction|| |
Dental caries is a multifactorial infectious oral disease caused primarily by the complex interaction of cariogenic oral flora, especially Streptococcus mutans (SM). The combined use of mechanical and chemical plaque control agents is effective in tackling this problem. Chlorhexidine digluconate is the most commonly used chemical plaque control agent. However, its long-term use has shown to cause various problems. Recently, use of natural products is gaining importance in all fields of medicine.
Honey has been considered an alternative medicine due to many health benefits such as wound healing, anti-inflammatory actions. Manuka honey (MH) is obtained from the flowers of Leptospermum scoparium tree containing at least 70% of pollen. It contains methylglyoxal, which is quintessential for its antibacterial, antifungal, antimicrobial, and antiseptic properties. The effective use of such honey may have important oral health implications.
Dental plaque has diverse bacterial composition. In vitro studies have demonstrated the effectiveness of MH as an antibacterial agent, especially against SM.,, Very few clinical studies have accessed the effect of MH on plaque, gingival status, and SM.,, Hence, the present study was carried out with an objective to assess the effectiveness of MH and 0.2% chlorhexidine digluconate (CHX) mouthwash on reducing gingivitis and SM count (SM) among children.
| Materials and Methods|| |
The present study is an experimental, parallel-group clinical trial conducted among school children aged 12–15 years from July 2019 to September 2019 in Bangalore city, India. A protocol of the intended study was submitted to the Institutional Ethical Committee (No: IEC-ACM /9/2018-19) and Review Board and ethical clearance was obtained. The procedures followed were in accordance with the Helsinki Declaration of 1975, as revised in 2013 and reported based on Consort guidelines.
The study was conducted for a period of 3 months from July 2019 to September 2019. A list of schools in Bangalore city was obtained. Four schools were randomly selected and assigned to MH group and chlorhexidine mouthwash group by lottery method. Permission was obtained from the principals of schools after explaining the purpose and procedure of the study. The study participants were informed about the study, the method of saliva collection, and the oral examination and were assured that their participation is purely voluntary. Written informed consent was obtained from the parents and assent from the children.
A block randomization method was employed. Bangalore city was arbitrarily divided into 4 zones and from each zone 1 school was selected randomly by employing lottery method, from the selected 4 schools, and 2 were selected randomly by employing lottery method. Random allocation of the dentifrice was done by a person not involved in the present study. A list of all students aged 12–15 years was obtained from school records. Recruitment was done based on the eligibility criteria till the required sample size was met. G Power software 220.127.116.11 (Franz Faul, Universitat Kiel, Germany) was used to calculate the sample size with a statistical power of 90% at 95% confidence interval and effect size (d) 0.8. Sample size calculated was 19, which was rounded off to 30 for each group considering dropouts. The investigator was trained and calibrated in the department of public health dentistry for the assessment of plaque and gingival Index,, DMFT, and saliva collection. Kappa co-efficient value (k) for intra-examiner reliability was 0.80–0.90 reflecting high degree of conformity in observation.
Children aged 12–15 years old with a moderate DMFT score 1–4 and plaque and gingival score of 1–2 were included in the study. Children who had undergone oral prophylaxis in last 6 months, history of antibiotic usage during the past 1 month, children already using any other mouth rinse, wearing orthodontic appliance, oral or systemic condition requiring emergency treatment, systemic condition or long-term/recent/current regimen of medication that can affect salivary flow, and history of adverse reactions to honey or chlorhexidine mouthwash were excluded from the study [Figure 1].
MH (UMF >15) and chlorhexidine digluconate (0.2%) mouthwash was procured commercially and was transferred into identical opaque bottles by an investigator who was not involved in the assessment of outcome measures. All the participants and investigators were blinded with respect to the mouthwash groups. The respective mouthwash as assigned was distributed to all 30 selected children from each school. The mouthwash with a measuring cup was distributed to the study participants. Participants were asked to hold 5 ml of MH in the mouth for 1 min and then expectorate, or rinse 10 ml of chlorhexidine mouthwash for 1 min in the respective groups. These agents were instructed to be used twice daily, morning after breakfast and night at least 1 h before going to bed for 14 days. They were instructed not to eat or drink anything for a minimum of half an hour after rinsing. Parents were educated regarding the use of mouthwash and were instructed to supervise the rinsing. Standard oral hygiene instructions were provided to all the participants. The subjects were asked to inform if they experienced any adverse effects with these agents.
Data were collected at baseline, 7th day, and 14th day during school working hours. Pro forma included demography, plaque and gingival scores, and compliance after using the agents. Plaque and gingival score using Silness and Löe Plaque Index and Löe and Silness Index Saliva was collected at baseline, 7th day, and 14th day during school working hours. All participants were given clear instructions to refrain from eating for 1 h before collection of saliva. Unstimulated whole saliva was collected by asking the children to pool saliva in the floor of the mouth without swallowing it for at least 1 min, and then to expectorate into the sterile test tube. Armamentarium used for the clinical examination and saliva collection included mouth mirror, Consumer Price Index probe, explorer, kidney trays, tweezers, cotton, gloves, mouth mask, saliva collection tubes, and disinfecting solution. A sufficient number of autoclaved instruments were taken for day-to-day examination. Infection control measures were observed throughout the study.
Saliva collected in the test tubes was transported to the microbiology laboratory. The saliva samples were homogenized manually by stirring using a stirrer. Hundred microliters of saliva was diluted with 1 ml of normal saline (1:10 dilution). Using an inoculation loop (2 mm inner diameter), 5 μl of the 1:10 dilution sample was streaked on mitis salivarius bacitracin agar (MSB), a selective medium for SM. The MSB agar plates were incubated for 48 h at 37°C. The colony count of each plate was recorded and the mean colony-forming Units (CFU/ml) was determined after multiplying the colony count of each plate with its respective dilution factor. All the microbiological procedures was performed by an investigator, who was blinded with respect to different groups throughout the study.
The data were analyzed using Statistical Package for Social Science (SPSS) version 22 (SPSS 22.0, IBM, Armonk, NY, USA). The P value was considered as significant when <0.05 (confidence interval of 95%). Descriptive analysis comparing mean standard deviation and percentage (proportion) was done for continuous and ordinal data, respectively. Normality of data was assessed using Shapiro–Wilk test. Student's unpaired t-test and repeated-measures analysis of variance (ANOVA) test were applied for inter- and intragroup comparison, respectively.
| Results|| |
The study included thirty children in both the groups (Flow diagram). There was no statistically significant difference in the two groups at the baseline according to age and gender [Table 1].
There was no statistically significant difference between the groups for the plaque scores, at baseline, 7th day, and 14th day. A significant reduction in mean plaque scores was identified at 7th day (0.85 ± 0.13) followed by further reduction on 14th day (0.57 ± 0.15) in MH group. A similar reduction in the plaque scores was identified in the chlorhexidine group. Repeated-measures ANOVA showed a significant difference within the MH group and chlorhexidine group in the plaque scores at 7th and 14th day from baseline [Table 2].
|Table 2: Mean plaque scores at baseline, 7th day, and 14th day among the study groups|
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Mean gingival scores have reduced significantly from baseline to 7th day and 14th day in both the groups. There was no statistically significant difference between the groups for the mean gingival scores at baseline, 7th day, and 14th day [Table 3].
|Table 3: Mean gingival scores at baseline, 7th day, and 14th day among the study groups|
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Mean SM score also showed a reduction from baseline to 7th day and 14th day in both the groups. There was no statistically significant difference between the groups. Repeated-measures ANOVA showed a significant difference within the MH and CHX group for the SM score from baseline to 7th and 14th day [Table 4].
|Table 4: Mean log values of Streptococcus mutans scores at baseline, 7th say, and 14th day among the study groups|
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| Discussion|| |
Honey is used as a natural sweetener with a high nutritive profile. Despite the fact that honey contains 70% sugar which is a cariogenic agent, it has been proved by various studies that honey has antibacterial properties that can counteract their anticaries activity. MH, although expensive, has often been used in different studies as the “gold standard” to test and evaluate the various biochemical properties of different kinds of honey from different botanical and geographical origins. The antibacterial activity of MH is primarily due to hydrogen peroxide formed in a slow-release manner by the enzyme glucose oxidase present in honey, which can vary widely in potency. However, in addition to this, MH contains nonperoxide antibacterial factors associated with its bioactive phytochemical components (UMF) such as D glucono δ-lactone, which reduces its pH and exerts natural antibacterial properties rendering it shelf-stable., Methylglyoxal (MGO), the aldehyde form of pyruvic acid, has been identified to be the chief antibacterial compound in it. Methylglyoxal is toxic toward pathogens even at low concentrations interrupting cell divisions, arresting growth, and specifically causing the degradation of bacterial DNA. Methyl syringate, ortho-methoxyacetophenone, and 3-phenyl lactic acid have been identified as other abundant components. Its low water activity (0.6–0.75) also renders it uninhabitable to most microbes.
Previous studies have reported MH with UMF ≥ 15 to be having antibacterial properties., The MH used in the present study had antibacterial activity rated UMF = 19. This study compared the effectiveness with chlorhexidine. CHX is considered a gold standard for reducing gingival and dental diseases. The most common and troublesome side effect of chlorhexidine is a brownish discoloration of teeth and tooth colored restoration. Dysgeusia and disturbances of the mucous membrane were also reported with chlorhexidine usage.
The study employed block randomization method, i.e. 30 children from each school were considered as a block/group for random allocation of the mouth rinse. This method was employed to blind the subjects with respect to the different mouth rinses used. As mouth rinses were of different color, taste, and flavor, the only way to blind the subjects and prevent cross-contamination of product information was by resorting to block randomization.
Participants with plaque scores between 1 and 2 were included in the present study to represent individuals with moderate amount of plaque deposition. The present clinical trial showed that MH and CHX were effective in reducing the mean plaque score over a period of 14 days. Although the method of application of honey varied, a similar reduction of plaque scores was reported in previous studies.,, Antiplaque effect of mouthwashes is explained by the inhibitory action on the bacteria forming the biofilm. Unique Manuka factor known as MGO present specifically in MH is toxic toward pathogens, interrupts cell divisions, and specifically causes the degradation of bacterial DNA. Other antibacterial properties are high osmolarity, flavonoids, and bee defensin-1. These factors together might have contributed to the antiplaque activity of MH, whereas Rölla and Melsen, suggested CHX reduced the number of bacteria in saliva available for adsorption on teeth and glycoprotein adsorption.
Reduction in a mean gingival score was observed from baseline to 7th and 14th day in MH group. This result was similar to the study done by Singh et al., where the anti-gingivitis effect of Honey was noted after using diluted MH mouthwash on children. Atwa et al. noticed a reduction in gingivitis among orthodontic patients after chewing lather made of MH. The most common form of gingivitis is associated with the accumulation of supragingival plaque along the gingival margins of the teeth. The reduction in gingivitis is attributed to the previously described antiplaque/antibiofilm potential of honey.
Subjects with a DMFT score of 1–4 were chosen to represent children with caries risk. Again, age is a critical factor in subject selection for many reasons, of which the most important is the number of tooth surfaces at risk. Subjects between 12 and 15 years were chosen since they were entering a period of high caries activity with many permanent teeth. Certain physiologic characteristics of the MS favor their reputation as a prime agent in caries which include ability to adhere to tooth surface, rapid production of abundant glucans from sucrose, rapid production of lactic acid from a number of sugar substrates, acid tolerance, and production of intracellular polysaccharide stores. Thus SM was assessed in the present study. MH caused a reduction in the adherence of plaque, thereby preventing the reducing the substrate for SM.
The antibacterial property of MH was reported in various in vitro studies. A clinical study has shown a significant reduction in SM count after 10 and 21 days of usage with MH in undiluted form. The present study has reported similar results on 7th and 14th day.
To the author's knowledge, this is the first study assessing the microbial and clinical effects of MH. Administration of both the agents may have the chance of contamination in the same schools which was avoided by administering the agents in different schools. Hence, blinding of participants could not be done in the study. Since the oral hygiene practices were standardized in the present study, the influence of that might not have affected the results. Usage of any mouthwash requires cooperation from the child; hence, the influence of behavior plays a major factor in the reduction microbial and clinical risk factors which would have contributed to response bias. Honey might be preferred to chlorhexidine because of its taste.
Hence, it can be concluded that MH and CHX mouthwash demonstrated equal effectiveness (P > 0.05) in reduction of clinical and microbial parameters. Manuka honey seems to be a promising antimicrobial agent effective against streptococcus mutans count and also improves gingival status and oral health.
We would like to acknowledge Mr Venkataswamy, microbiologist, for supporting us throughout the study. We would also like to acknowledge all the principals of the school, children, and their parents who cooperated throughout the study.
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]