ORIGINAL Chainani ARTICLE et al
Antiplaque and Antigingivitis Efficacy of Triphala and Chlorhexidine Mouthrinse Among Schoolchildren – A Cross-over, Double-blind, Randomised Controlled Trial Swati H. Chainania/Sunitha Siddanab/CVK Reddyc/ Thippeswamy H. Manjunathappab/Maurya Manjunathd/Sushma Rudraswamyd Purpose: To evaluate and compare the effect of triphala extract mouthrinse and chlorhexidine on dental plaque and gingivitis. Materials and Methods: In this double blind, crossover study, 120 qualifying boarding-school students aged 13–16 years were randomised into three groups: 10% triphala, 0.1% chlorhexidine and negative control. The study was conducted in 3 phases of 1-month duration each and a washout period of 15 days. During the experimental period, subjects rinsed with the allocated mouthrinse once daily for 30 s under supervision. The plaque and gingival status was assessed using the Turesky modification of the Quigley and Hein plaque index (QHI) and the gingival index (Löe and Silness) at baseline and at the end of each phase. The results were tested for significance at p < 0.05. Results: Triphala and chlorhexidine yielded a significant reduction in plaque and gingival index scores as compared to negative control (p < 0.001). No significant difference was found between the scores obtained with triphala and chlorhexidine mouthwashes. Conclusion: The antiplaque and antigingivitis activity of triphala closely parallels that of chlorhexidine. Key words: antigingivitis, antiplaque, chlorhexidine, triphala Oral Health Prev Dent 2014;12:209-217 doi: 10.3290/j.ohpd.a32674
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pidemiological studies have shown that periodontitis, an inflammatory disease of the periodontium, is one of the most common afflictions of mankind (Peterson et al, 2005). Inflammatory lesions of the gingiva, if left untreated, may eventually compromise the entire periodontal attachment apparatus of the affected teeth, leading to their loss. Tooth loss often compromises function and aesthetics and may be associated with discomfort.
a
Postgraduate Student, Department of Public Health Dentistry, JSS Dental College and Hospital, Mysore, Karnataka, India.
b
Reader, Department of Public Health Dentistry, JSS Dental College and Hospital, Mysore, Karnataka, India.
c
Professor and Head, Department of Public Health Dentistry, JSS Dental College and Hospital, Mysore, Karnataka, India.
d
Senior Lecturer, Department of Public Health Dentistry, JSS Dental College and Hospital, Mysore, Karnataka, India.
Correspondence: Dr. Swati H. Chainani, Department of Public Health Dentistry, JSS Dental College and Hospital, JSS University, Sri Shivarathreeshwara Nagar, Bannimantap, Mysore 570015, Karnataka, India. Tel: +91-0953-828-3600. Email: drswatichainani@ gmail.com
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Submitted for publication: 17.11.12; accepted for publication: 09.07.13
In addition, recent studies suggest that such chronic, low-grade localised infections can be associated with systemic health problems, including cardiovascular disease, pre-term and low birth weight infants and diabetes mellitus. Hence, control of this low-grade chronic infection has gained priority in recent years (Lagervall et al, 2003). The role of plaque as a causative factor of periodontal disease is well established. Dental plaque is a complex mixture of bacteria with representatives from more than 500 species enmeshed in a tightly adherent biofilm. Ideally, supragingival plaque control should prevent periodontal tissue inflammation and breakdown. The incorporation of broad-spectrum antimicrobial mouthrinses as adjuncts to a personal daily oral hygiene regimen has assumed greater importance with the recognition that most individuals are unable to consistently maintain adequate levels of plaque control using mechanical methods alone (Hull, 1980). The finding that 0.2% chlorhexidine
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mouthrinse can effectively prevent plaque and gingivitis in the absence of other oral hygiene procedures using an experimental gingivitis model (Löe et al, 1976) established the potential for antimicrobial mouthrinses in clinical practice. As a result of the accumulated literature and clinical experience, chlorhexidine became the gold standard of antimicrobial mouthrinses in dentistry. However, its side effects – e.g. staining of the teeth and tooth-coloured restorations, alteration in taste sensation and increased calculus formation – precludes its long-term use (McCoy et al, 2008). During the past several years, there has been a worldwide move towards the use of traditional medicines (WHO, 2002). Medicinal plants have always been an integral part of Indian civilisation for combatting a variety of diseases (Maurya et al, 1997). Research has been focused in recent years on herbal medicines, owing to their wide range of biological and medicinal activities, ease of availability, higher safety margins and lower cost (Cowan, 1999). One such herbal remedy is triphala, an equiproportional mixture of Terminalia chebula, Terminalia bellerica and Emblicus officialis. It has been used extensively in the Indian system of medicine as a potent anti-inflammatory (Jagadish et al, 2009), antioxidant (Asmawi, 1993) and antimicrobial agent against a wide spectrum of microbes (Biradar, 2008). However, literature on its effect in the oral cavity is scarce. The current study was undertaken to evaluate and compare the effect of mouthrinse containing triphala extract and chlorhexidine on dental plaque and gingivitis in schoolchildren aged 13–16 years in Mysore city, India.
MATERIALS AND METHODS This was a double-blind, cross-over, randomised controlled trial employing a Latin square pattern designed to evaluate and compare the effect of triphala extract mouthrinse and chlorhexidine on dental plaque and gingivitis. The study was conducted at a randomly selected boarding school of Mysore city after obtaining necessary permission from the responsible authorities. Approval from the institutional Ethics Committee was obtained before initiating the study. The study design is illustrated in Fig 1.
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Preparation of the mouthrinses Triphala was prepared from the fruits of each species by mixing them in equal proportions (1:1:1) based on the Ayurvedic Formulary of India (Indian Pharmacopoie Committee, 2007). An alcoholic extract of triphala was obtained using the cold maceration technique with 97% ethanol as the solvent (Naik, 2006). 10% triphala mouthrinse was prepared by adding 100 g of the extract to 1 liter of sterile distilled water. Commercial 0.2% chlorhexidine solution (Hexidine, ICPA Health Products; Mumbai, India) was diluted to a 1:1 concentration, so that the final solution used was 0.1%. Sterile distilled water was used as the negative control. All the mouthrinses were freshly prepared every 3 days at the JSS College of Pharmacy, Mysore. Solutions were made of identical colour and taste to eliminate bias. The content of the solutions were known to the person who prepared the solutions and were disclosed to the investigator at the end of the study.
Sampling and subjects Sample size estimation was done from the results of the pilot study, which suggested that the study be designed to detect a mean difference of 0.8 in gingival scores between the test and the control group. To detect this mean difference of 0.8 at 80% power of the study and assuming a standard deviation of ±1 for the difference, the sample size estimated was 26 for each regimen. To compensate for any dropouts, a sample size of 40 subjects per group was used in this study, thus totaling 120 subjects. Before the start of this study, informed consent from the principal of the school and the parents of the students participating in this study was obtained. The children also gave consent to participate. The inclusion criteria for enrollment in the study were: subjects aged 13–16 years with a minimum of 20 teeth and willingness to comply with the appointment schedule. The exclusion criteria for the study were: presence of any systemic disease, allergy or infectious disease, subject undergoing antibiotic therapy or anti-inflammatory therapy, subject was already using any mouthrinse, wearing an orthodontic appliance or removable partial denture.
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Assessed for eligibility (n = 150) Excluded (n = 30) • Did not meet inclusion criteria (n = 10) • Declined to participate (n = 15) • Other reasons (n = 5)
Enrollment
Randomised (n = 120)
Allocation
Group A (n = 40) (placebo)
Group B (n = 40) (triphala)
Group C (n = 40) (chlorhexidine)
Follow-up
Lost to follow-up (n = 0)
Lost to follow-up (n = 0)
Lost to follow-up (n = 2) due to absence on day of examination
Crossover, washout period 15 days
Group A (n = 40) (chlorhexidine)
Group B (n = 40) (placebo)
Group C (n = 38) (triphala)
Follow up
Lost to follow-up (n = 3) Noncompliant
Lost to follow-up (n = 4) 2 = antibiotic intake 2 = noncompliant
Lost to follow-up (n = 4) 2 = antibiotic intake 2 = noncompliant
Crossover, washout period 15 days
Group A (n = 37) (triphala)
Group B (n = 36) (chlorhexidine)
Group C (n = 34) (placebo)
Follow-up
Total analysed = 107
Fig 1 Flow diagram of study design (CONSORT, 2010).
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An equal number of age- and gender-matched subjects were selected for the study (girls, n = 60; boys, n = 60). Three groups were drawn randomly from these, with each group consisting of 40 subjects with an equal number of boys and girls. The study was conducted between January and May, 2012. Each group was subjected to all three interventions in a phased manner. Subjects rinsed with 20 ml of allocated mouthrinse for 30 s once daily, including weekends, under supervision to ensure good distribution around the mouth. They were instructed not to rinse with water, eat or drink for one hour afterwards. Each experimental phase lasted for 1 month, during which subjects continued their routine oral hygiene procedures, followed by a washout period of 15 days. The groups were given next mouthrinse according to the Latin square pattern in the subsequent phases. In the present trial, the data were continuously monitored to determine whether the study should be stopped early because of harmful effects or unexpectedly large beneficial effects. This function was performed by the faculty, Department of Public Health Dentistry, JSS Dental College and Hospital.
Data collection and statistical analysis All the examinations were carried out by a single, trained examiner. Reliability was established with a kappa statistic of 0.87 for the plaque index and 0.79 for the gingival index, which reflects high degree of conformity in observations. The general information was recorded on the specially designed form. The plaque and gingival status was assessed using the Turesky modification of the Quigley and Hein plaque index (Turesky et al, 1970) and the gingival index by Löe and Silness (Löe et al, 1963) at baseline and the end of each phase. The collected data were subjected to statistical analysis. For intragroup comparison of plaque and gingival scores, the paired sample t-test was applied, while for the intergroup comparison ANOVA and the post-hoc Tukey test were applied. A general linear analysis model was applied to compare the relative effect of test product, phase and group effect on plaque and gingival scores. The level of significance was set at p < 0.05. Data were analysed using Microsoft Excel and SPSS 17. The results are reported in accordance with the CONSORT checklist for randomised trials (see Appendix; CONSORT, 2010).
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RESULTS There was attrition of the sample in all three groups. At the end of the second phase of the trial, there were 3, 4, and 6 dropouts from the chlorhexidine, placebo and triphala groups, respectively. The overall attrition rate was 10.8%. No adverse events or side effects were reported or observed. Baseline demographic information showed all the subjects brushed using a toothbrush and toothpaste once daily. The three groups did not show any significant difference at baseline. Table 1 depicts the intergroup comparison of mean plaque and gingival scores. ANOVA showed a significant post-intervention difference for each group (p < 0.001). Multiple comparisons for plaque and gingival index scores using the post-hoc Tukey test is depicted in Table 2. A statistically significant difference was found between control vs chlorhexidine and triphala, with a mean plaque score reduction of 1.35 ± 0.05 (p > 0.001) and 1.32 ± 0.05 (p > 0.001), respectively. A statistically significant difference was found between the negative control and both chlorhexidine and triphala, with a mean gingival score reduction of 1.39 ± 0.05 (p > 0.001) and 1.34 ± 0.05 (p > 0.001), respectively. The difference between triphala and chlorhexidine was found to be non-significant. Univariate analysis was used to study the between-subject effects with plaque and gingival index scores as dependent variables. Each term in the model, plus the model as a whole, was tested for its ability to account for variation in the plaque and gingival index scores. In terms of plaque and gingival score reduction, the test products showed a significant effect (R2 = 0.707 and 0.726 respectively, Table 3).
DISCUSSION This study was undertaken to explore the antiplaque and antigingivitis efficacy of triphala vs the gold standard, chlorhexidine. The present study is a randomised controlled trial with a cross-over design using a Latin square pattern. The advantage of this design is that the subjects themselves act as their own control and hence the expected subject variance is minimised. The study was conducted among schoolchildren aged 13–16 years, since this age group is vulnerable to developing gingivitis due to hormonal chang-
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Table 1 Phasewise intergroup comparison of plaque and gingival index scores Phase I
Group
Phase II
Phase III
Baseline
PI
Baseline
PI
Baseline
PI
Mean (SD)
Mean (SD)
Mean (SD)
Mean (SD)
Mean (SD)
Mean (SD)
Plaque index score Placebo
1.89 (0.44)
1.76 (0.44)
2.01 (0.49)
0.52 (0.22)
1.82 (0.35)
0.45 (0.13)
Triphala
1.72 (0.31)
0.43 (0.15)
1.93 (0.25)
1.71 (0.43)
1.91 (0.41)
0.43 (0.16)
Chlorhexidine
1.84 (0.48)
0.44 (0.25)
2.04 (0.4)
0.49 (0.13)
1.98 (0.43)
1.92 (0.41)
ANOVA (p- value)
1.553 (0.216) NS
236.072 (0.001)
0.791 (0.456) NS
48.338 (0.001)
1.361 (0.261) NS
375.370 (0.001)
Gingival Index Score Placebo
1.52 (0.38)
1.34 (0.82)
1.36 (0.30)
0.44 (0.14)
1.46 (0.45)
0.47 (0.14)
Triphala
1.60 (0.31)
0.44 (0.17)
1.35 (0.25)
1.33 (0.37)
1.39 (0.26)
0.43 (0.13)
Chlorhexidine
1.56 (0.45)
0.42 (0.18)
1.28 (0.21)
0.32 (0.14)
1.46 (0.28)
1.44 (0.83)
ANOVA (p-value)
0.44 (0.646)
43.05 (0.001)
1.040 (0.357)
178.94 (0.001)
0.53 (0.593)
48.21 (0.001)
*Statistically significant association using ANOVA at p < 0.05. NS: not significant; PI: post-intervention; SD: standard deviation.
Table 2 Multiple comparision for plaque and gingival index score using Tukey’s HSD Product
Mean Difference
Std. Error
p-value
CI (95%)
Plaque index score Negative control vs triphala
1.32
0.05
0.001*
1.19–1.45
Negative control vs chlorhexidine
1.35
0.05
0.001*
1.21–1.48
Triphala vs chlorhexidine
0.03
0.05
0.891
-0.11–0.16
Gingival index score Negative control vs triphala
1.34
0.05
0.001*
1.21–1.46
Negative control vs chlorhexidine
1.39
0.05
0.001*
1.26–1.52
Triphala vs chlorhexidine
0.05
0.05
0.559
-0.07–0.18
CI: confidence interval. *Statistically significant.
Table 3 Univariate analysis of plaque and gingival scores Plaque score Estimate Intercept
272.3
Phase
0.269
Error
Gingival score 2
Estimate
p-value
R
0.000
0.837
266.1
0.45
0.005
1.10
53.20
Error
p-value
R2
0.00
0.838
0.032
0.021
51.42
Group
0.545
0.20
0.010
0.33
0.351
0.006
Test Product
128.61
0.000
0.707
136.3
0.001
0.726
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es, changing dietary patterns, incorrect brushing habits and lack of motivation, leading to gingivitis and enhanced plaque formation. Fifteen-year-olds are also an age group recommended as representative by the WHO in its basic oral health survey (WHO, 1997). The sampling method employed involved stratified randomisation. Equal numbers of females and males were randomly distributed in each group to balance out any influence of hormones among gingival status. An in vitro study reported a reduction of 83% of Streptococcus mutans at a 5% concentration and 86% reduction at a 10% concentration of triphala (Jagdish et al, 2009). Based on this finding, it was decided to use the 10% concentration for the present study. In order to minimise the risk of carry-over effect, a washout period of 15 days was observed between each treatment phase. This was based on the fact that the residual effect of chlorhexidine differs from that of an inert rinse, such as water or saline. Consequently, a longer washout period, such as 10 days or more, is preferable (Newcombe et al, 1995). The effectiveness of triphala mouthrinse was intended to be studied in a real-life situation and hence no oral prophylaxis was performed. At the end of the second phase of the trial, the 3, 4 and 6 subjects dropped out of the chlorhexidine, placebo and triphala groups, respectively. The reasons were non-availability on the day of examination, non-adherence to the protocol and 4 subjects had started taking antibiotics for medical reasons. This, however, did not affect the power of the study, since 10% more subjects were recruited in each group to compensate for attrition. Hence, no drop-out analysis was performed. In the present study, a 0.1% chlorhexidine mouthrinse was found to be effective in reducing the plaque and gingival index score to a statistically significant level (p < 0.001). This is in agreement with the studies conducted Lang et al (1986), Moran et al (1991) and Quiryen et al (2001). Furthermore, 10% triphala extract showed a statistically significant reduction in plaque and gingival scores (p < 0.001) as compared to the negative control. This is in conformity with the study conducted by Bajaj et al (2011), who concluded that there was no significant difference between the triphala and the chlorhexidine mouthwash. The results obtained in the current study can be attributed to the antimicrobial and antiplaque activity of
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triphala, as also found by Jagadish et al (2009), who studied the effect of triphala on dental biofilm. Sushruta (Maurya et al, 1997) has described that triphala pacifies the kapha (mucus, water) and pitta (bile, fire) dosha, which – according to Ayurvedic medicine – are the main causative factors of periodontal diseases. He also emphasised that triphala has haemostatic, anti-inflammatory, analgesic and wound healing properties. T. chebula is most efficacious against bleeding gums, gingival ulcers and tooth decay (Maurya et al, 1997). Biradar et al (2008) chemically analysed triphala, and reported tannic acid, chebulic acid and flavinoids as its major constituents. The presence of tannins in triphala during the early stages of plaque formation could effectively reduce the number of bacteria available for binding to the tooth surface by increasing their physical removal from the oral cavity through aggregate formation. It is known that tannins have a very high binding affinity for certain proteins, resulting in their precipitation. Alternatively, the tannins could be associated with surface lipoteichoic acid, as in the case of salivary acidic glycoproteins, resulting in bacterial aggregation. Additionally, the effective inhibition of glucosyltransferase activity and reduced bacterial adhesion to hydroxyapatite, as seen with the presence of tannin extracts, suggests some antiplaque activity. Kaikuchi et al (1986) reported that the galloyl radical of the tannins was important for inhibition of glucan activity and the anti-plaque activity of the tannins. Peroxidation of the biological membrane occurs at the tissue level during gingival inflammation. It is mediated by various bacterial and/or host-derived oxygen species such as hydroxyl radicals, singlet molecular oxygen, free oxygen radicals and superoxide anions. A decrease in the oxidation of the host tissues may resolve inflammatory changes (Firatli et al, 1994). Triphala exhibits a strong antioxidant property, as confirmed by Hazra et al (2010), Jagadish et al (2009) and Lee et al (2005). Their results indicate that the fruit extracts contain significant amount of flavonoids and phenolic compounds, where T. bellerica > E. officinalis > T. chebula and E. officinalis > T. bellerica > T. chebula, respectively. The mechanism of action of flavonoids is through scavenging and chelating processes, while phenols scavenge hydroxyl radicals. E. officinalis contains enormous amounts of ascorbic acid that acts as a chainbreaking antioxidant and impairs the formation of
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free radicals throughout the body. This might explain the significant reduction in the gingival score reduction in the triphala group (Hazra et al, 2010).
CONCLUSION The results of this clinical trial on the two mouthrinses containing 10% triphala or 0.1% chlorhexidine showed clinically and statistically significant antiplaque and antigingivitis properties vs the negative control. No significant difference in the effectiveness was found between the two mouthrinses. Thus, it can be concluded that the antiplaque and antigingivitis activity of triphala is very similar to that of chlorhexidine.
REFERENCES 1. Asmawi MZ, Kankaanrata H, Vapaatalo H. Anti-inflammatory activity of Emblica officialis Gaertn leaf extract. J. Pharm Pharmacol 1993;45:581–584. 2. Bajaj N, Tandon S. The effect of Triphala and chlorhexidine mouthwash on dental plaque, gingival inflammation, and microbial growth. Int J Ayurveda Res 2011;2:29–36. 3. Biradar YS, Jagatap S, Khandelwal KR, Singhania SS. Exploring of antimicrobial activity of Triphala Mashi – an Ayurvedic formulation. Evid Based Complement Alternat Med 2008;5:107–113. 4. CONSORT checklist and flow diagram for randomized controlled trials, 2010. Available at http://www.consort-statement.org 5. Firatli E, Unal T, Onan U, Sandalli P. Antioxidant activities of some chemotherapeutics. A possible mechanism in reducing gingival inflammation. J Clin Periodontol 1994;21: 680–683. 6. Hazra B, Sarkar R, Biswas S, Mandal N. Comparative study of antioxidant potential and reactive oxygen species scavenging properties in extracts of fruits of Terminalia chebula, Terminalia bellerica and Emblica officinalis. BMC Complementary and Alternative Medicine 2010;10:1–15. 7. Hull PS. Chemical inhibition of plaque. J Clin Periodontol 1980;7:431–442. 8. Indian Pharmacopoie Committee. Ayurvedic Formulary of India, Part I, 6:14. New Delhi: Govt. of India, Ministry of Health and Family Planning, Dept. of AYUSH, 2007:90–95.
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9. Jagadish L, Anandkumar VK, Kaviyarasan V. Role of Triphala on dental biofilms. Indian J Sci Technol 2009;2: 30–33. 10. Kakiuchi N, Hattori M, Nishizawa M, Yamagishi T, Okuda T, Namba T. Studies on dental caries prevention by traditional medicines. VIII. Inhibitory effect of various tannins on glucan synthesis by glycosyltransferases from Streptococcus mutans. Chem Pharm Bull 1986;34:720–725. 11. Lagervall M. Systemic disorders in patients with periodontal disease. J Clin Periodontol 2003;30:293–299. 12. Lang NP, Brecx CM. Chlorhexidine digluconate – an agent for chemical plaque control and prevention of gingival inflammation. J Periodontal Res 1986;21(suppl 16):74–89. 13. Lee H S, Won N H, Kim K H, Lee H, Jun W, Lee K W. Antioxidant effects of aqueous extract of Terminalia chebula in vivo and in vitro. Biol Pharm Bull 2005;28:1639–1644. 14. Löe H, Schiott C R, Giavind, Kakring T. Two years oral use of Chlorhexidine in man. General designs and clinical effects. J Periodontal Res 1976;11:135–144 15. Maurya DK, Mittal N, Sharma KR. Role of Triphala in management of periodontal disease. Ancient Science of Life 1997;17:1–6. 16. McCoy LC, Wehler CJ, Rich SE. Adverse events associated with chlorhexidine use. JADA 2008;139:178–183. 17. Moran J, Pal D, Newcombe R, Addy M. Comparison of a phenolic and a 0.2% chlorhexidine mouthwash on the development of plaque and gingivitis. Clin Prev Dent 1991;13:31–35. 18. Naik G H, Priyadarshini K I, Mohan H. Free radical scavenging reactions and phytochemical analysis of Triphala in ayurvedic formulations. Current Science 2006;90:1100–1104. 19. Newcombe RD, Addy M, Mckeown S: Residual effect of Chlorhexidine gluconate in a five day plaque regrowth crossover trials, and its implication for study design. J Periodont Res 1995;30:319–324. 20. Peterson PE, Yammato 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. 21. Quirynen M, Avontroodt P. Effect of different Chlorhexidine formulations on de novo plaque formation. J Clin Periodontol 2001;28:1127–1136. 22. Turesky S, Gilmore ND, Glickman I. Reduced plaque formation by the chloromethyl analogue of vitamin C. J Periodontol 1970;41:41–43. 23. World Health Organization. Basic oral health survey. WHO: Geneva, 1997. 24. World Health Organization. Traditional medicine: growing needs and potential. WHO policy perspectives on Medicines. WHO: Geneva, 2002.
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APPENDIX CONSORT 2010 checklist of information to include when reporting a randomised trial* Section/Topic
Item No
Checklist item
Reported
Title and abstract 1a
Identification as a randomised trial in the title
No
1b
Structured summary of trial design, methods, results, and conclusions (for specific guidance see CONSORT for abstracts)
Yes
2a
Scientific background and explanation of rationale
Yes
2b
Specific objectives or hypotheses
Yes
3a
Description of trial design (such as parallel, factorial) including allocation ratio
Yes
3b
Important changes to methods after trial commencement (such as eligibility criteria), with reasons
No
4a
Eligibility criteria for participants
Yes
4b
Settings and locations where the data were collected
Yes
5
The interventions for each group with sufficient details to allow replication, including how and when they were actually administered
Yes
6a
Completely defined pre-specified primary and secondary outcome measures, including how and when they were assessed
Yes
6b
Any changes to trial outcomes after the trial commenced, with reasons
No
7a
How sample size was determined
Yes
7b
When applicable, explanation of any interim analyses and stopping guidelines
Yes
8a
Method used to generate the random allocation sequence
Yes
8b
Type of randomisation; details of any restriction (such as blocking and block size)
Yes
Allocation concealment mechanism
9
Mechanism used to implement the random allocation sequence (such as sequentially numbered containers), describing any steps taken to conceal the sequence until interventions were assigned
Yes
Ementation
10
Who generated the random allocation sequence, who enrolled participants, and who assigned participants to interventions
Yes
11a
If done, who was blinded after assignment to interventions (for example, participants, care providers, those assessing outcomes) and how
Yes
11b
If relevant, description of the similarity of interventions
12a
Statistical methods used to compare groups for primary and secondary outcomes
12b
Methods for additional analyses, such as subgroup analyses and adjusted analyses
Introduction Background and objectives Methods
Trial design
Participants
Interventions
Outcomes
Sample size Randomisation Sequence generation
Blinding
Statistical methods
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Not applicable Yes Not applicable
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APPENDIX continued Section/Topic
Item No
Checklist item
Reported
Results 13a
For each group, the numbers of participants who were randomly assigned, received intended treatment, and were analysed for the primary outcome
Yes
13b
For each group, losses and exclusions after randomisation, together with reasons
Yes
14a
Dates defining the periods of recruitment and follow-up
Yes
14b
Why the trial ended or was stopped
Baseline data
15
A table showing baseline demographic and clinical characteristics for each group
Yes
Numbers analysed
16
For each group, number of participants (denominator) included in each analysis and whether the analysis was by original assigned groups
Yes
17a
For each primary and secondary outcome, results for each group, and the estimated effect size and its precision (such as 95% confidence interval)
Yes
17b
For binary outcomes, presentation of both absolute and relative effect sizes is recommended
Ancillary analyses
18
Results of any other analyses performed, including subgroup analyses and adjusted analyses, distinguishing pre-specified from exploratory
No
Harms
19
All important harms or unintended effects in each group (for specific guidance see CONSORT for harms)
Yes
Limitations
20
Trial limitations, addressing sources of potential bias, imprecision, and, if relevant, multiplicity of analyses
Yes
Generalisability
21
Generalisability (external validity, applicability) of the trial findings
Yes
Interpretation
22
Interpretation consistent with results, balancing benefits and harms, and considering other relevant evidence
Yes
Registration
23
Registration number and name of trial registry
No
Protocol
24
Where the full trial protocol can be accessed, if available
No
Funding
25
Sources of funding and other support (such as supply of drugs), role of funders
Participant flow (a diagram is strongly recommended)
Recruitment
Outcomes and estimation
Not applicable
Not applicable
Discussion
Other information
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Not applicable
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Antiplaque and Antigingivitis Efficacy of Triphala and Chlorhexidine Mouthrinse Among Schoolchildren – A Cross-over, Double-blind, Randomised Controlled Trial Swati H. Chainania/Sunitha Siddanab/CVK Reddyc/ Thippeswamy H. Manjunathappab/Maurya Manjunathd/Sushma Rudraswamyd Purpose: To evaluate and compare the effect of triphala extract mouthrinse and chlorhexidine on dental plaque and gingivitis. Materials and Methods: In this double blind, crossover study, 120 qualifying boarding-school students aged 13–16 years were randomised into three groups: 10% triphala, 0.1% chlorhexidine and negative control. The study was conducted in 3 phases of 1-month duration each and a washout period of 15 days. During the experimental period, subjects rinsed with the allocated mouthrinse once daily for 30 s under supervision. The plaque and gingival status was assessed using the Turesky modification of the Quigley and Hein plaque index (QHI) and the gingival index (Löe and Silness) at baseline and at the end of each phase. The results were tested for significance at p < 0.05. Results: Triphala and chlorhexidine yielded a significant reduction in plaque and gingival index scores as compared to negative control (p < 0.001). No significant difference was found between the scores obtained with triphala and chlorhexidine mouthwashes. Conclusion: The antiplaque and antigingivitis activity of triphala closely parallels that of chlorhexidine. Key words: antigingivitis, antiplaque, chlorhexidine, triphala Oral Health Prev Dent 2014;12:209-217 doi: 10.3290/j.ohpd.a32674
E
pidemiological studies have shown that periodontitis, an inflammatory disease of the periodontium, is one of the most common afflictions of mankind (Peterson et al, 2005). Inflammatory lesions of the gingiva, if left untreated, may eventually compromise the entire periodontal attachment apparatus of the affected teeth, leading to their loss. Tooth loss often compromises function and aesthetics and may be associated with discomfort.
a
Postgraduate Student, Department of Public Health Dentistry, JSS Dental College and Hospital, Mysore, Karnataka, India.
b
Reader, Department of Public Health Dentistry, JSS Dental College and Hospital, Mysore, Karnataka, India.
c
Professor and Head, Department of Public Health Dentistry, JSS Dental College and Hospital, Mysore, Karnataka, India.
d
Senior Lecturer, Department of Public Health Dentistry, JSS Dental College and Hospital, Mysore, Karnataka, India.
Correspondence: Dr. Swati H. Chainani, Department of Public Health Dentistry, JSS Dental College and Hospital, JSS University, Sri Shivarathreeshwara Nagar, Bannimantap, Mysore 570015, Karnataka, India. Tel: +91-0953-828-3600. Email: drswatichainani@ gmail.com
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Submitted for publication: 17.11.12; accepted for publication: 09.07.13
In addition, recent studies suggest that such chronic, low-grade localised infections can be associated with systemic health problems, including cardiovascular disease, pre-term and low birth weight infants and diabetes mellitus. Hence, control of this low-grade chronic infection has gained priority in recent years (Lagervall et al, 2003). The role of plaque as a causative factor of periodontal disease is well established. Dental plaque is a complex mixture of bacteria with representatives from more than 500 species enmeshed in a tightly adherent biofilm. Ideally, supragingival plaque control should prevent periodontal tissue inflammation and breakdown. The incorporation of broad-spectrum antimicrobial mouthrinses as adjuncts to a personal daily oral hygiene regimen has assumed greater importance with the recognition that most individuals are unable to consistently maintain adequate levels of plaque control using mechanical methods alone (Hull, 1980). The finding that 0.2% chlorhexidine
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mouthrinse can effectively prevent plaque and gingivitis in the absence of other oral hygiene procedures using an experimental gingivitis model (Löe et al, 1976) established the potential for antimicrobial mouthrinses in clinical practice. As a result of the accumulated literature and clinical experience, chlorhexidine became the gold standard of antimicrobial mouthrinses in dentistry. However, its side effects – e.g. staining of the teeth and tooth-coloured restorations, alteration in taste sensation and increased calculus formation – precludes its long-term use (McCoy et al, 2008). During the past several years, there has been a worldwide move towards the use of traditional medicines (WHO, 2002). Medicinal plants have always been an integral part of Indian civilisation for combatting a variety of diseases (Maurya et al, 1997). Research has been focused in recent years on herbal medicines, owing to their wide range of biological and medicinal activities, ease of availability, higher safety margins and lower cost (Cowan, 1999). One such herbal remedy is triphala, an equiproportional mixture of Terminalia chebula, Terminalia bellerica and Emblicus officialis. It has been used extensively in the Indian system of medicine as a potent anti-inflammatory (Jagadish et al, 2009), antioxidant (Asmawi, 1993) and antimicrobial agent against a wide spectrum of microbes (Biradar, 2008). However, literature on its effect in the oral cavity is scarce. The current study was undertaken to evaluate and compare the effect of mouthrinse containing triphala extract and chlorhexidine on dental plaque and gingivitis in schoolchildren aged 13–16 years in Mysore city, India.
MATERIALS AND METHODS This was a double-blind, cross-over, randomised controlled trial employing a Latin square pattern designed to evaluate and compare the effect of triphala extract mouthrinse and chlorhexidine on dental plaque and gingivitis. The study was conducted at a randomly selected boarding school of Mysore city after obtaining necessary permission from the responsible authorities. Approval from the institutional Ethics Committee was obtained before initiating the study. The study design is illustrated in Fig 1.
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Preparation of the mouthrinses Triphala was prepared from the fruits of each species by mixing them in equal proportions (1:1:1) based on the Ayurvedic Formulary of India (Indian Pharmacopoie Committee, 2007). An alcoholic extract of triphala was obtained using the cold maceration technique with 97% ethanol as the solvent (Naik, 2006). 10% triphala mouthrinse was prepared by adding 100 g of the extract to 1 liter of sterile distilled water. Commercial 0.2% chlorhexidine solution (Hexidine, ICPA Health Products; Mumbai, India) was diluted to a 1:1 concentration, so that the final solution used was 0.1%. Sterile distilled water was used as the negative control. All the mouthrinses were freshly prepared every 3 days at the JSS College of Pharmacy, Mysore. Solutions were made of identical colour and taste to eliminate bias. The content of the solutions were known to the person who prepared the solutions and were disclosed to the investigator at the end of the study.
Sampling and subjects Sample size estimation was done from the results of the pilot study, which suggested that the study be designed to detect a mean difference of 0.8 in gingival scores between the test and the control group. To detect this mean difference of 0.8 at 80% power of the study and assuming a standard deviation of ±1 for the difference, the sample size estimated was 26 for each regimen. To compensate for any dropouts, a sample size of 40 subjects per group was used in this study, thus totaling 120 subjects. Before the start of this study, informed consent from the principal of the school and the parents of the students participating in this study was obtained. The children also gave consent to participate. The inclusion criteria for enrollment in the study were: subjects aged 13–16 years with a minimum of 20 teeth and willingness to comply with the appointment schedule. The exclusion criteria for the study were: presence of any systemic disease, allergy or infectious disease, subject undergoing antibiotic therapy or anti-inflammatory therapy, subject was already using any mouthrinse, wearing an orthodontic appliance or removable partial denture.
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Assessed for eligibility (n = 150) Excluded (n = 30) • Did not meet inclusion criteria (n = 10) • Declined to participate (n = 15) • Other reasons (n = 5)
Enrollment
Randomised (n = 120)
Allocation
Group A (n = 40) (placebo)
Group B (n = 40) (triphala)
Group C (n = 40) (chlorhexidine)
Follow-up
Lost to follow-up (n = 0)
Lost to follow-up (n = 0)
Lost to follow-up (n = 2) due to absence on day of examination
Crossover, washout period 15 days
Group A (n = 40) (chlorhexidine)
Group B (n = 40) (placebo)
Group C (n = 38) (triphala)
Follow up
Lost to follow-up (n = 3) Noncompliant
Lost to follow-up (n = 4) 2 = antibiotic intake 2 = noncompliant
Lost to follow-up (n = 4) 2 = antibiotic intake 2 = noncompliant
Crossover, washout period 15 days
Group A (n = 37) (triphala)
Group B (n = 36) (chlorhexidine)
Group C (n = 34) (placebo)
Follow-up
Total analysed = 107
Fig 1 Flow diagram of study design (CONSORT, 2010).
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An equal number of age- and gender-matched subjects were selected for the study (girls, n = 60; boys, n = 60). Three groups were drawn randomly from these, with each group consisting of 40 subjects with an equal number of boys and girls. The study was conducted between January and May, 2012. Each group was subjected to all three interventions in a phased manner. Subjects rinsed with 20 ml of allocated mouthrinse for 30 s once daily, including weekends, under supervision to ensure good distribution around the mouth. They were instructed not to rinse with water, eat or drink for one hour afterwards. Each experimental phase lasted for 1 month, during which subjects continued their routine oral hygiene procedures, followed by a washout period of 15 days. The groups were given next mouthrinse according to the Latin square pattern in the subsequent phases. In the present trial, the data were continuously monitored to determine whether the study should be stopped early because of harmful effects or unexpectedly large beneficial effects. This function was performed by the faculty, Department of Public Health Dentistry, JSS Dental College and Hospital.
Data collection and statistical analysis All the examinations were carried out by a single, trained examiner. Reliability was established with a kappa statistic of 0.87 for the plaque index and 0.79 for the gingival index, which reflects high degree of conformity in observations. The general information was recorded on the specially designed form. The plaque and gingival status was assessed using the Turesky modification of the Quigley and Hein plaque index (Turesky et al, 1970) and the gingival index by Löe and Silness (Löe et al, 1963) at baseline and the end of each phase. The collected data were subjected to statistical analysis. For intragroup comparison of plaque and gingival scores, the paired sample t-test was applied, while for the intergroup comparison ANOVA and the post-hoc Tukey test were applied. A general linear analysis model was applied to compare the relative effect of test product, phase and group effect on plaque and gingival scores. The level of significance was set at p < 0.05. Data were analysed using Microsoft Excel and SPSS 17. The results are reported in accordance with the CONSORT checklist for randomised trials (see Appendix; CONSORT, 2010).
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RESULTS There was attrition of the sample in all three groups. At the end of the second phase of the trial, there were 3, 4, and 6 dropouts from the chlorhexidine, placebo and triphala groups, respectively. The overall attrition rate was 10.8%. No adverse events or side effects were reported or observed. Baseline demographic information showed all the subjects brushed using a toothbrush and toothpaste once daily. The three groups did not show any significant difference at baseline. Table 1 depicts the intergroup comparison of mean plaque and gingival scores. ANOVA showed a significant post-intervention difference for each group (p < 0.001). Multiple comparisons for plaque and gingival index scores using the post-hoc Tukey test is depicted in Table 2. A statistically significant difference was found between control vs chlorhexidine and triphala, with a mean plaque score reduction of 1.35 ± 0.05 (p > 0.001) and 1.32 ± 0.05 (p > 0.001), respectively. A statistically significant difference was found between the negative control and both chlorhexidine and triphala, with a mean gingival score reduction of 1.39 ± 0.05 (p > 0.001) and 1.34 ± 0.05 (p > 0.001), respectively. The difference between triphala and chlorhexidine was found to be non-significant. Univariate analysis was used to study the between-subject effects with plaque and gingival index scores as dependent variables. Each term in the model, plus the model as a whole, was tested for its ability to account for variation in the plaque and gingival index scores. In terms of plaque and gingival score reduction, the test products showed a significant effect (R2 = 0.707 and 0.726 respectively, Table 3).
DISCUSSION This study was undertaken to explore the antiplaque and antigingivitis efficacy of triphala vs the gold standard, chlorhexidine. The present study is a randomised controlled trial with a cross-over design using a Latin square pattern. The advantage of this design is that the subjects themselves act as their own control and hence the expected subject variance is minimised. The study was conducted among schoolchildren aged 13–16 years, since this age group is vulnerable to developing gingivitis due to hormonal chang-
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Table 1 Phasewise intergroup comparison of plaque and gingival index scores Phase I
Group
Phase II
Phase III
Baseline
PI
Baseline
PI
Baseline
PI
Mean (SD)
Mean (SD)
Mean (SD)
Mean (SD)
Mean (SD)
Mean (SD)
Plaque index score Placebo
1.89 (0.44)
1.76 (0.44)
2.01 (0.49)
0.52 (0.22)
1.82 (0.35)
0.45 (0.13)
Triphala
1.72 (0.31)
0.43 (0.15)
1.93 (0.25)
1.71 (0.43)
1.91 (0.41)
0.43 (0.16)
Chlorhexidine
1.84 (0.48)
0.44 (0.25)
2.04 (0.4)
0.49 (0.13)
1.98 (0.43)
1.92 (0.41)
ANOVA (p- value)
1.553 (0.216) NS
236.072 (0.001)
0.791 (0.456) NS
48.338 (0.001)
1.361 (0.261) NS
375.370 (0.001)
Gingival Index Score Placebo
1.52 (0.38)
1.34 (0.82)
1.36 (0.30)
0.44 (0.14)
1.46 (0.45)
0.47 (0.14)
Triphala
1.60 (0.31)
0.44 (0.17)
1.35 (0.25)
1.33 (0.37)
1.39 (0.26)
0.43 (0.13)
Chlorhexidine
1.56 (0.45)
0.42 (0.18)
1.28 (0.21)
0.32 (0.14)
1.46 (0.28)
1.44 (0.83)
ANOVA (p-value)
0.44 (0.646)
43.05 (0.001)
1.040 (0.357)
178.94 (0.001)
0.53 (0.593)
48.21 (0.001)
*Statistically significant association using ANOVA at p < 0.05. NS: not significant; PI: post-intervention; SD: standard deviation.
Table 2 Multiple comparision for plaque and gingival index score using Tukey’s HSD Product
Mean Difference
Std. Error
p-value
CI (95%)
Plaque index score Negative control vs triphala
1.32
0.05
0.001*
1.19–1.45
Negative control vs chlorhexidine
1.35
0.05
0.001*
1.21–1.48
Triphala vs chlorhexidine
0.03
0.05
0.891
-0.11–0.16
Gingival index score Negative control vs triphala
1.34
0.05
0.001*
1.21–1.46
Negative control vs chlorhexidine
1.39
0.05
0.001*
1.26–1.52
Triphala vs chlorhexidine
0.05
0.05
0.559
-0.07–0.18
CI: confidence interval. *Statistically significant.
Table 3 Univariate analysis of plaque and gingival scores Plaque score Estimate Intercept
272.3
Phase
0.269
Error
Gingival score 2
Estimate
p-value
R
0.000
0.837
266.1
0.45
0.005
1.10
53.20
Error
p-value
R2
0.00
0.838
0.032
0.021
51.42
Group
0.545
0.20
0.010
0.33
0.351
0.006
Test Product
128.61
0.000
0.707
136.3
0.001
0.726
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es, changing dietary patterns, incorrect brushing habits and lack of motivation, leading to gingivitis and enhanced plaque formation. Fifteen-year-olds are also an age group recommended as representative by the WHO in its basic oral health survey (WHO, 1997). The sampling method employed involved stratified randomisation. Equal numbers of females and males were randomly distributed in each group to balance out any influence of hormones among gingival status. An in vitro study reported a reduction of 83% of Streptococcus mutans at a 5% concentration and 86% reduction at a 10% concentration of triphala (Jagdish et al, 2009). Based on this finding, it was decided to use the 10% concentration for the present study. In order to minimise the risk of carry-over effect, a washout period of 15 days was observed between each treatment phase. This was based on the fact that the residual effect of chlorhexidine differs from that of an inert rinse, such as water or saline. Consequently, a longer washout period, such as 10 days or more, is preferable (Newcombe et al, 1995). The effectiveness of triphala mouthrinse was intended to be studied in a real-life situation and hence no oral prophylaxis was performed. At the end of the second phase of the trial, the 3, 4 and 6 subjects dropped out of the chlorhexidine, placebo and triphala groups, respectively. The reasons were non-availability on the day of examination, non-adherence to the protocol and 4 subjects had started taking antibiotics for medical reasons. This, however, did not affect the power of the study, since 10% more subjects were recruited in each group to compensate for attrition. Hence, no drop-out analysis was performed. In the present study, a 0.1% chlorhexidine mouthrinse was found to be effective in reducing the plaque and gingival index score to a statistically significant level (p < 0.001). This is in agreement with the studies conducted Lang et al (1986), Moran et al (1991) and Quiryen et al (2001). Furthermore, 10% triphala extract showed a statistically significant reduction in plaque and gingival scores (p < 0.001) as compared to the negative control. This is in conformity with the study conducted by Bajaj et al (2011), who concluded that there was no significant difference between the triphala and the chlorhexidine mouthwash. The results obtained in the current study can be attributed to the antimicrobial and antiplaque activity of
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triphala, as also found by Jagadish et al (2009), who studied the effect of triphala on dental biofilm. Sushruta (Maurya et al, 1997) has described that triphala pacifies the kapha (mucus, water) and pitta (bile, fire) dosha, which – according to Ayurvedic medicine – are the main causative factors of periodontal diseases. He also emphasised that triphala has haemostatic, anti-inflammatory, analgesic and wound healing properties. T. chebula is most efficacious against bleeding gums, gingival ulcers and tooth decay (Maurya et al, 1997). Biradar et al (2008) chemically analysed triphala, and reported tannic acid, chebulic acid and flavinoids as its major constituents. The presence of tannins in triphala during the early stages of plaque formation could effectively reduce the number of bacteria available for binding to the tooth surface by increasing their physical removal from the oral cavity through aggregate formation. It is known that tannins have a very high binding affinity for certain proteins, resulting in their precipitation. Alternatively, the tannins could be associated with surface lipoteichoic acid, as in the case of salivary acidic glycoproteins, resulting in bacterial aggregation. Additionally, the effective inhibition of glucosyltransferase activity and reduced bacterial adhesion to hydroxyapatite, as seen with the presence of tannin extracts, suggests some antiplaque activity. Kaikuchi et al (1986) reported that the galloyl radical of the tannins was important for inhibition of glucan activity and the anti-plaque activity of the tannins. Peroxidation of the biological membrane occurs at the tissue level during gingival inflammation. It is mediated by various bacterial and/or host-derived oxygen species such as hydroxyl radicals, singlet molecular oxygen, free oxygen radicals and superoxide anions. A decrease in the oxidation of the host tissues may resolve inflammatory changes (Firatli et al, 1994). Triphala exhibits a strong antioxidant property, as confirmed by Hazra et al (2010), Jagadish et al (2009) and Lee et al (2005). Their results indicate that the fruit extracts contain significant amount of flavonoids and phenolic compounds, where T. bellerica > E. officinalis > T. chebula and E. officinalis > T. bellerica > T. chebula, respectively. The mechanism of action of flavonoids is through scavenging and chelating processes, while phenols scavenge hydroxyl radicals. E. officinalis contains enormous amounts of ascorbic acid that acts as a chainbreaking antioxidant and impairs the formation of
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free radicals throughout the body. This might explain the significant reduction in the gingival score reduction in the triphala group (Hazra et al, 2010).
CONCLUSION The results of this clinical trial on the two mouthrinses containing 10% triphala or 0.1% chlorhexidine showed clinically and statistically significant antiplaque and antigingivitis properties vs the negative control. No significant difference in the effectiveness was found between the two mouthrinses. Thus, it can be concluded that the antiplaque and antigingivitis activity of triphala is very similar to that of chlorhexidine.
REFERENCES 1. Asmawi MZ, Kankaanrata H, Vapaatalo H. Anti-inflammatory activity of Emblica officialis Gaertn leaf extract. J. Pharm Pharmacol 1993;45:581–584. 2. Bajaj N, Tandon S. The effect of Triphala and chlorhexidine mouthwash on dental plaque, gingival inflammation, and microbial growth. Int J Ayurveda Res 2011;2:29–36. 3. Biradar YS, Jagatap S, Khandelwal KR, Singhania SS. Exploring of antimicrobial activity of Triphala Mashi – an Ayurvedic formulation. Evid Based Complement Alternat Med 2008;5:107–113. 4. CONSORT checklist and flow diagram for randomized controlled trials, 2010. Available at http://www.consort-statement.org 5. Firatli E, Unal T, Onan U, Sandalli P. Antioxidant activities of some chemotherapeutics. A possible mechanism in reducing gingival inflammation. J Clin Periodontol 1994;21: 680–683. 6. Hazra B, Sarkar R, Biswas S, Mandal N. Comparative study of antioxidant potential and reactive oxygen species scavenging properties in extracts of fruits of Terminalia chebula, Terminalia bellerica and Emblica officinalis. BMC Complementary and Alternative Medicine 2010;10:1–15. 7. Hull PS. Chemical inhibition of plaque. J Clin Periodontol 1980;7:431–442. 8. Indian Pharmacopoie Committee. Ayurvedic Formulary of India, Part I, 6:14. New Delhi: Govt. of India, Ministry of Health and Family Planning, Dept. of AYUSH, 2007:90–95.
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9. Jagadish L, Anandkumar VK, Kaviyarasan V. Role of Triphala on dental biofilms. Indian J Sci Technol 2009;2: 30–33. 10. Kakiuchi N, Hattori M, Nishizawa M, Yamagishi T, Okuda T, Namba T. Studies on dental caries prevention by traditional medicines. VIII. Inhibitory effect of various tannins on glucan synthesis by glycosyltransferases from Streptococcus mutans. Chem Pharm Bull 1986;34:720–725. 11. Lagervall M. Systemic disorders in patients with periodontal disease. J Clin Periodontol 2003;30:293–299. 12. Lang NP, Brecx CM. Chlorhexidine digluconate – an agent for chemical plaque control and prevention of gingival inflammation. J Periodontal Res 1986;21(suppl 16):74–89. 13. Lee H S, Won N H, Kim K H, Lee H, Jun W, Lee K W. Antioxidant effects of aqueous extract of Terminalia chebula in vivo and in vitro. Biol Pharm Bull 2005;28:1639–1644. 14. Löe H, Schiott C R, Giavind, Kakring T. Two years oral use of Chlorhexidine in man. General designs and clinical effects. J Periodontal Res 1976;11:135–144 15. Maurya DK, Mittal N, Sharma KR. Role of Triphala in management of periodontal disease. Ancient Science of Life 1997;17:1–6. 16. McCoy LC, Wehler CJ, Rich SE. Adverse events associated with chlorhexidine use. JADA 2008;139:178–183. 17. Moran J, Pal D, Newcombe R, Addy M. Comparison of a phenolic and a 0.2% chlorhexidine mouthwash on the development of plaque and gingivitis. Clin Prev Dent 1991;13:31–35. 18. Naik G H, Priyadarshini K I, Mohan H. Free radical scavenging reactions and phytochemical analysis of Triphala in ayurvedic formulations. Current Science 2006;90:1100–1104. 19. Newcombe RD, Addy M, Mckeown S: Residual effect of Chlorhexidine gluconate in a five day plaque regrowth crossover trials, and its implication for study design. J Periodont Res 1995;30:319–324. 20. Peterson PE, Yammato 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. 21. Quirynen M, Avontroodt P. Effect of different Chlorhexidine formulations on de novo plaque formation. J Clin Periodontol 2001;28:1127–1136. 22. Turesky S, Gilmore ND, Glickman I. Reduced plaque formation by the chloromethyl analogue of vitamin C. J Periodontol 1970;41:41–43. 23. World Health Organization. Basic oral health survey. WHO: Geneva, 1997. 24. World Health Organization. Traditional medicine: growing needs and potential. WHO policy perspectives on Medicines. WHO: Geneva, 2002.
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APPENDIX CONSORT 2010 checklist of information to include when reporting a randomised trial* Section/Topic
Item No
Checklist item
Reported
Title and abstract 1a
Identification as a randomised trial in the title
No
1b
Structured summary of trial design, methods, results, and conclusions (for specific guidance see CONSORT for abstracts)
Yes
2a
Scientific background and explanation of rationale
Yes
2b
Specific objectives or hypotheses
Yes
3a
Description of trial design (such as parallel, factorial) including allocation ratio
Yes
3b
Important changes to methods after trial commencement (such as eligibility criteria), with reasons
No
4a
Eligibility criteria for participants
Yes
4b
Settings and locations where the data were collected
Yes
5
The interventions for each group with sufficient details to allow replication, including how and when they were actually administered
Yes
6a
Completely defined pre-specified primary and secondary outcome measures, including how and when they were assessed
Yes
6b
Any changes to trial outcomes after the trial commenced, with reasons
No
7a
How sample size was determined
Yes
7b
When applicable, explanation of any interim analyses and stopping guidelines
Yes
8a
Method used to generate the random allocation sequence
Yes
8b
Type of randomisation; details of any restriction (such as blocking and block size)
Yes
Allocation concealment mechanism
9
Mechanism used to implement the random allocation sequence (such as sequentially numbered containers), describing any steps taken to conceal the sequence until interventions were assigned
Yes
Ementation
10
Who generated the random allocation sequence, who enrolled participants, and who assigned participants to interventions
Yes
11a
If done, who was blinded after assignment to interventions (for example, participants, care providers, those assessing outcomes) and how
Yes
11b
If relevant, description of the similarity of interventions
12a
Statistical methods used to compare groups for primary and secondary outcomes
12b
Methods for additional analyses, such as subgroup analyses and adjusted analyses
Introduction Background and objectives Methods
Trial design
Participants
Interventions
Outcomes
Sample size Randomisation Sequence generation
Blinding
Statistical methods
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Not applicable Yes Not applicable
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APPENDIX continued Section/Topic
Item No
Checklist item
Reported
Results 13a
For each group, the numbers of participants who were randomly assigned, received intended treatment, and were analysed for the primary outcome
Yes
13b
For each group, losses and exclusions after randomisation, together with reasons
Yes
14a
Dates defining the periods of recruitment and follow-up
Yes
14b
Why the trial ended or was stopped
Baseline data
15
A table showing baseline demographic and clinical characteristics for each group
Yes
Numbers analysed
16
For each group, number of participants (denominator) included in each analysis and whether the analysis was by original assigned groups
Yes
17a
For each primary and secondary outcome, results for each group, and the estimated effect size and its precision (such as 95% confidence interval)
Yes
17b
For binary outcomes, presentation of both absolute and relative effect sizes is recommended
Ancillary analyses
18
Results of any other analyses performed, including subgroup analyses and adjusted analyses, distinguishing pre-specified from exploratory
No
Harms
19
All important harms or unintended effects in each group (for specific guidance see CONSORT for harms)
Yes
Limitations
20
Trial limitations, addressing sources of potential bias, imprecision, and, if relevant, multiplicity of analyses
Yes
Generalisability
21
Generalisability (external validity, applicability) of the trial findings
Yes
Interpretation
22
Interpretation consistent with results, balancing benefits and harms, and considering other relevant evidence
Yes
Registration
23
Registration number and name of trial registry
No
Protocol
24
Where the full trial protocol can be accessed, if available
No
Funding
25
Sources of funding and other support (such as supply of drugs), role of funders
Participant flow (a diagram is strongly recommended)
Recruitment
Outcomes and estimation
Not applicable
Not applicable
Discussion
Other information
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Not applicable
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