|Year : 2022 | Volume
| Issue : 4 | Page : 427-431
Effect of pomegranate mouthrinse on gingival health: A 21 day randomised controlled clinical trial
Charu Mohan Marya, Swati Singroha, Ruchi Nagpal, Pratibha Taneja, Sakshi Kataria, Parul Kashyap
Department of Public Health Dentistry, Sudha Rustagi College of Dental Sciences and Research, Faridabad, Haryana, India
|Date of Submission||22-Oct-2021|
|Date of Decision||24-Aug-2022|
|Date of Acceptance||28-Sep-2022|
|Date of Web Publication||19-Dec-2022|
Department of Public Health Dentistry, Sudha Rustagi College of Dental Sciences and Research, Faridabad, Haryana
Source of Support: None, Conflict of Interest: None
Aim: To evaluate the efficacy of Punica granatum mouthrinse as compared to 0.12% chlorhexidine (CHX) on periodontal health. Settings and Design: This was a randomized controlled trial among patients aged ≥40 years selected from the outpatient department of Sudha Rustagi College of Dental Sciences and Research. Methodology: Fifty subjects diagnosed with chronic generalized gingivitis were selected and randomly divided into two groups, i.e., P. granatum mouthrinse group and CHX group. The mouthrinse extract was prepared using peel of P. granatum fruit. Patients were advised to use their prescribed mouthwash for 21 days. Clinical evaluation was done at baseline, 7 days, 14 days, and 21 days using the gingival index and the plaque index. Statistical Analysis Used: SPSS Inc 21 software (Statistical Package for the Social Sciences) was used. For inferential statistics, Friedman test, Wilcoxon signed-rank test, and Mann–Whitney U-test were used. Results: There was significant improvement in gingival status in both the sites. Subjects using P. granatum rinse showed significant improvement in gingival scores as compared with CHX. In contrast, P. granatum was shown not to be so effective in reducing plaque scores. Conclusions: P. granatum rinse is beneficial in improving gingival status due to its profound styptic action, with sufficient reduction in plaque scores.
Keywords: Chlorhexidine, gingival scores, herbal mouthrinse, plaque scores, pomegranate, pomegranate extract, Punica granatum
|How to cite this article:|
Marya CM, Singroha S, Nagpal R, Taneja P, Kataria S, Kashyap P. Effect of pomegranate mouthrinse on gingival health: A 21 day randomised controlled clinical trial. J Indian Assoc Public Health Dent 2022;20:427-31
| Introduction|| |
Since ages, chlorhexidine (CHX) has been the gold standard due to its profound antibacterial and antiplaque efficacy, but there are certain side effects pertaining to CHX use. So only, numerous herbal products have been tested for antiplaque or antigingivitis efficacy where Punica granatum has been recently proved effective as herbal medicine. P. granatum is commonly known as “pomegranate.” It exhibits antibacterial, antifungal, antioxidant, anticarcinogenic, and anti-inflammatory properties. It has properties that could lessen the possibility of gingivitis and improve overall oral health. To our knowledge, very few studies are found in literature regarding the beneficial effect of P. granatum on dental plaque and gingivitis among children and adolescents. Hence, the aim of the study was to evaluate the efficacy of P. granatum mouthrinse as compared to 0.12% CHX mouthrinse in reducing bacterial plaque and gingivitis.
| Methodology|| |
The present randomized controlled trial was conducted to compare the efficacy of two different mouthwashes, namely, P. granatum mouthrinse and CHX mouthrinse against plaque status and gingival status. Approval for the study was obtained from the institutional ethical committee and the trial was registered in CTRI (CTRI-CTRI/2019/09/02141). This trial was conducted according to the guidelines of CONSORT.
This study was triple-blinded, parallel-group randomized controlled trial with coequal randomization, conducted among 50 patients from the department of public health dentistry of the institution aged 18–25 years spanning over a period of 21 days.
The eligibility criteria derived from the acceptance program guidelines for chemotherapeutic products controlling gingivitis given by The American Dental Association were used to recruit the trial participants. The concentration of P. granatum extract mouthrinse used in the present was 0.05%.
Sample size was calculated using Sealed Envelope Ltd. 2012 for noninferiority trials. Anticipating if there was truly no difference between the standard and experimental treatment, then 50 patients were required to be 80% sure that the lower limit of a one-sided 95% confidence interval (or equivalently a 90% two-sided confidence interval) will be above the noninferiority limit of −0.5.
Subjects having moderate-to-severe periodontitis, undergoing antibiotic treatment or had it in last 1 month, using antimicrobial mouthrinses or at a high polyphenol diet or subjects with smoking habits or had any history of periodontal treatment within the last 3 months were excluded from the study. Thorough clinical examination was done for the recruited subjects. The subjects were provided with detailed information sheet, explaining about the principles of treatment and purpose of the study. Subjects who gave informed consent were randomly assigned to two parallel groups in 1:1 ratio, to receive either P. granatum mouthrinse or CHX mouthrinse, respectively, using lottery method. Allocation of subjects into study groups was done by another examiner who was not involved in the measurement of the outcome. In this way, allocation concealment was ensured.
Preparation of mouthrinse
The peel of a pomegranate fruit was first thoroughly rinsed with water and dried under sunlight until complete evaporation of water droplets. The pericarp (peel) was then kept in a hot air oven for 5–6 days at 33°C to dry completely. The dried pericarp was then ground to powder. 250 ml of boiling water and 5 g of ground pericarp were mixed. The mixture was left in a hot water bath for an hour at 70°C to completely extract the secondary metabolites. Filtration of the extract was done using Whatman number one filter paper. The filtered extract was then dried using a hot air oven. The dried extract was dissolved in a four times the volume of dimethyl sulfoxide to a concentration of 50 mg/mL. The solution was prepared over a period of 15 days and kept away from direct sunlight.
Group A (n = 25) was given 0.05% P. granatum mouthrinse and instructed to rinse with 10 ml of solution twice daily for 30 s at the interval of 12 h for 21 days. Group B (n = 25) was given commercial formulation of 0.12% CHX mouthrinse and instructed to rinse with 10 ml (as per manufacturer's guidelines) of solution twice daily for 30 s at the interval of 12 h for 21 days. Medicine cups were provided to measure the quantity of mouthrinse.
Every participant was given one bottle of mouthrinse every week for 3 weeks containing 140 ml of mouthrinse. Hence, a total of 420 ml was dispensed to each subject and told to return back the bottle along with remaining quantity at the end of study. To check the compliance of subjects for given mouthrinse used, the remaining quantity of mouthrinse was measured in each bottle at the end of the study.
The primary outcome measure was gingival health which was assessed using Loe and Silness gingival index (GI) and plaque scores which were assessed using Turesky-Gilmore modification of Quigley hein plaque index (PI), scores on 7 days, 14 days and 21 days. Any adverse or unintended effects of mouthrinse were taken as secondary outcome measures. A single-trained and calibrated examiner performed all the measurement of clinical parameters. To limit intra-examiner variability, the examiner was trained under the guidance of a professional with expertise in the clinical field. The training continued until consistent readings were obtained.
Descriptive and inferential statistics was performed using IBM Statistical Package for the Social Sciences SPSS-21 (IBM Inc., Armonk, NY, USA). Graphs were prepared on Microsoft Excel. GI and PI scores were summarized as means and standard deviation Owing to ordinal nature of the study outcome variable nonparametric tests of significance were used for inferential statistics. For intragroup comparison, Friedman test was used, followed by Wilcoxon signed-rank test for pairwise comparison. Mann–Whitney U-test was used for the comparison of mean values of two groups.
| Results|| |
Background characteristics of the study population are depicted in [Table 1]. The two groups comprised 10 females and 40 males. Of these, 3 females and 22 males were in Group I (P. granatum) and 7 females and 18 males were in Group II (CHX). The mean age was found to be significantly more in P. granatum group, i.e., 22.6 years as compared to the subjects of CHX group, i.e., 21.2 years.
[Table 2] shows intergroup and intragroup comparison of GI scores of the study population at baseline to postintervention. The mean GI at baseline was 1.56 ± 0.08 and 1.60 ± 0.08 among Group I and Group II, respectively. Whereas, postintervention mean was found to be 1.05 ± 0.04 and 1.06 ± 0.08 among Group I and Group II, respectively. Intragroup difference between baseline and postintervention score was assessed using the Friedman test, followed by Wilcoxon signed-rank test. Among both the groups, there was a statistically significant reduction (P > 0.05) in GI from baseline to postintervention. Intergroup differences at baseline and postintervention were assessed using Mann–Whitney U-test. When the differences in mean GI score between the two study groups were compared at baseline and 1 week, no statistical significant difference was seen as P ≥ 0.05. However, the differences in mean GI score between the two study groups at 2 weeks and 3 week were found to be statistical significant, i.e., GI scores were found to be significantly higher among Group II subjects compared to Group I subjects.
|Table 2: Inter and intra group comparison of gingival index scores among two study groups at different time intervals|
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[Table 3] shows intergroup and intragroup comparison of PI scores at different time intervals. The mean plaque at baseline was 2.02 ± 0.25 and 2.09 ± 0.25 among Groups I and II, respectively. Postintervention, the mean in Group I was 1.69 ± 0.26 and in Group II was 1.59 ± 0.24. Intragroup difference between baseline and postintervention score was assessed using the Friedman test and Wilcoxon signed-rank test. Both the groups showed a statistically significant difference in mean PI scores from baseline to 1 week, baseline to 2 weeks, and baseline to 3 weeks, i.e., maximum reduction in mean PI scores was seen from baseline to 3 weeks followed by 2 weeks and 1 week. Intergroup differences at baseline and postintervention were assessed using Mann–Whitney U-test, it failed to reach the level of statistical significance at all intervals, i.e., plaque scores were found to be comparable among two study groups.
|Table 3: Inter and intra group comparison of plaque index scores among two study groups at different time intervals|
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[Table 4] shows intergroup and intragroup comparison of mean percentage reduction in GI scores and PI scores. For the GI score, the mean percentage reduction from baseline to postintervention was 18.1 ± 6.49 and 32.4% ±3.5 for Group I and 17.8 ± 6.40 and 29.6 ± 5.1 for Group II. When this difference in mean percentage reduction in gingival score between the two study groups was compared from baseline to 3 week, a statistically significant difference was seen as P < 0.05. Percentage reduction in mean GI score was found to be higher in Group I subjects than Group II subjects when compared from baseline to 3 weeks. For PI score, the mean percentage reduction from baseline to postintervention was found to be 3.67 ± 3.17 and 13.58 ± 4.3 in Group I, whereas in Group II, it was found to be 5.31 ± 4.13 at baseline to 25.42 ± 5.96 postintervention. When this difference in mean % reduction in plaque score between the two study groups was compared from baseline to 2 week and from baseline to 3 week, a statistically significant difference was seen at P < 0.05. The percentage reduction in mean PI score was found to be higher in Group II subjects than Group I subjects.
|Table 4: Intergroup comparison of mean percentage reduction in gingival index scores and plaque index scores|
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| Discussion|| |
The present study assessed the antiplaque and antigingivitis efficacy of a pomegranate mouthrinse with 0.2% CHX solution serving as comparison group. Findings of the present study indicated antiplaque and antigingivitis effect of pomegranate mouthrinse but without any statistically significant difference between the two interventions provided to the study population. Due to paucity of literature documenting the effect of P. granatum on dental plaque and gingival health, the results of the present study were evaluated parallel inferences taken off from nonspecialized articles.
GI scores were found to be significantly higher among CHX group subjects. Similar findings have been reported by Bhadbhade et al. where antiplaque efficacy was found to be maximum for P. granatum as compared to CHX as positive control and distilled water as negative control. This could be attributed to the fact that pomegranate contains polyphenols, tannins, and flavonoids which possess antioxidant and anti-inflammatory properties. Pomegranate flavonoid extract possessed direct antioxidant properties such as radical scavenging ability and induction of endogenous properties and also the restriction of low stimuli activation of inflammatory processes. This could be the probable reason for the antigingivitis effect of P. granatum. CHX continues to remain most widely accepted broad spectrum antiseptic mouthrinse that is equally effective against Gram-positive, Gram-negative bacteria and other microorganism like yeast, fungi.
Contrary to the results of the present study, a clinical trial by Salgado et al., 10% P. granatum gel was not found to be efficient in preventing gingivitis. Probably, this could be due to the reason that P. granatum gel was delivered to the test quadrant using tooth shield. At the same time, subjects were refrained from brushing the test quadrant, while the other teeth were normally brushed three times a day using the dentifrice.
Analysis of PI suggested that both the mouthrinses used in the present study reduced plaque score, but no significant difference in antiplaque efficacy could be appreciated among two study groups. These findings are in agreement with the studies conducted by Overholser et al. and Haffajee et al. and Bhadbhade et al. A microbiological study conducted by Menezes et al. showed better antiplaque efficacy of P. granatum compared to CHX. A probable reason for this could be difference in the methodology applied in these two studies, i.e., instead of PI score, microbial colony-forming units were recorded. The plaque inhibitory effect of pomegranate can be attributed to the ability to remove dental plaque as P. granatum extract can inhibit a bacterial sucrose-digesting enzyme responsible for initiating plaque formation. In the present study, no side effects of P. granatum mouthrinse were found on subjective examination. Similar results were obtained from the study conducted on herbal mouthrinse by Parwani et al. and Dalai et al.
However, it is a newly researched herbal product used in the field of dentistry. Hence, more clinical and microbiological studies on a long-term period with different concentration are required to prove its efficacy as compared to CHX mouthrinse, which continues to remain the gold standard.
One shortcoming of the study is the small sample size and parallel research design. In parallel study designs, patient-related factors such as oral hygiene and lifestyle-related habits could also confound the study results. Apart from this, external validity of the study is also limited as the trial was conducted among young adults to avoid any extraneous effect of periodontal pockets on the efficacy of newly proposed mouthrinse on gingival health. Hence the results can not be generalised over middle aged or elderly population.
A clinical trial with crossover design with longer duration and larger sample size needs to be conducted to establish the efficacy and better extrapolation of the results. Extending the duration of the follow-up period may also enable detection of further changes.
| Conclusions|| |
Our study concluded that both the study groups showed antiplaque and antigingivitis effect. However, P. granatum mouthrinse showed superior antigingivitis efficacy than CHX, but not as effective against dental plaque as CHX. The treatment with P. granatum could be used as it is easy to prepare, has profound styptic action, and shows acceptable reduction in plaque scores. More clinical trials are required to know the effectiveness of P. granatum and its advantage over the prototype chemical plaque control agent, i.e., CHX, which is still a gold standard for reduction of plaque scores.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Flotra L. Different modes of chlorhexidine application and related local side effects. J Periodontal Res Suppl 1973;12:41-4.
Dalai DR, Tangade P, Punia H, Ghosh S, Singh N, Garg Y. Evaluation of anti-gingivitis efficacy of Punica granatum
mouthwash and 0.2% chlorhexidine gluconate mouthwash through a 4 day randomized controlled trial. Arch Dent Med Res 2016;2:9-14.
Bhadbhade SJ, Acharya AB, Rodrigues SV, Thakur SL. The antiplaque efficacy of pomegranate mouthrinse. Quintessence Int 2011;42:29-36.
DiSilvestro RA, DiSilvestro DJ, DiSilvestro DJ. Pomegranate extract mouth rinsing effects on saliva measures relevant to gingivitis risk. Phytother Res 2009;23:1123-7.
Loe H, Silness J. Periodontal disease in pregnancy: Prevalence and severity. Acta Odontol Scand 1963;21:533-51.
Deepak JC, Samuel SR. Effectiveness of pomegranate mouthrinse in reducing bacterial plaque, gingival inflammation and total salivary proteins over a period of 90 days: A double-blind randomized trial. J Int Acad Periodontol 2018;20:110-4.
Silness J, loe H. Periodontal disease in pregnancy. II. Correlation between oral hygiene and periodontal condtion. Acta Odontol Scand 1964;22:121-35.
Turesky S, Gilmore ND, Glickman I. Reduced plaque formation by the chloromethyl analogue of victamine C. J Periodontol 1970;41:41-3.
Quigley GA, Hein JW. Comparative cleansing efficiency of manual and power brushing. J Am Dent Assoc 1962;65:26-9.
Ahuja S, Dodwad V, Kukreja BJ, Mehra P, Kukreja P. A comparative evaluation of efficacy of Punica granatum
and chlorhexidine on plaque and gingivitis. J Int Clin Dent Res Org 2011;3:29-32.
Salgado AD, Maia JL, Pereira SL, de Lemos TL, Mota OM. Antiplaque and antigingivitis effects of a gel containing Punica granatum
Linn extract: A double-blind clinical study in humans. J Appl Oral Sci 2006;14:162-6.
Overholser CD, Meiller TF, DePaola LG, Minah GE, Niehaus C. Comparative effects of 2 chemotherapeutic mouthrinses on the development of supragingival dental plaque and gingivitis. J Clin Periodontol 1990;17:575-9.
Haffajee AD, Yaskell T, Socransky SS. Antimicrobial effectiveness of an herbal mouthrinse compared with an essential oil and a chlorhexidine mouthrinse. J Am Dent Assoc 2008;139:606-11.
Menezes SM, Cordeiro LN, Viana GS. Punica granatum
(pomegranate) extract is active against dental plaque. J Herb Pharmacother 2006;6:79-92.
Parwani SR, Parwani RN, Chitnis PJ, Dadlani HP, Prasad SV. Comparative evaluation of anti-plaque efficacy of herbal and 0.2% chlorhexidine gluconate mouthwash in a 4-day plaque re-growth study. J Indian Soc Periodontol 2013;17:72-7.
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[Table 1], [Table 2], [Table 3], [Table 4]