Journal of Investigative and Clinical Dentistry (2014), 5, 1–5
ORIGINAL ARTICLE Community Dentistry and Oral Epidemiology
Efficacy of triphala mouth rinse (aqueous extracts) on dental plaque and gingivitis in children Ritesh Bhattacharjee1, Sridhar Nekkanti2, Nikesh G. Kumar1, Ketan Kapuria1, Shashidhar Acharya1 & Kalyana C. Pentapati1 1 Department of Public Health Dentistry, Manipal College of Dental Sciences, Manipal University, Manipal, Karnataka, India 2 Department of Pedodontics and Preventive Dentistry, Manipal College of Dental Sciences, Manipal University, Manipal, Karnataka, India
Keywords chlorhexidine, gingivitis, herbal, plaque, triphala. Correspondence Assistant Professor K. C. Pentapati, Department of Public Health Dentistry, Manipal College of Dental Sciences, Madhav Nagar, Manipal University, Manipal, Karnataka 576104, India. Tel: +91-99160-36303 Email: [email protected] Received 15 February 2013; accepted 14 January 2014. doi: 10.1111/jicd.12094
Abstract Aim: The aim of the present study was to evaluate the efficacy of triphala mouth rinse (aqueous) in the reduction of plaque and gingivitis among children. Methods: The study was a randomized, double-blinded, controlled trial, with a total of 60 school children (n = 30 in each group; triphala and chlorhexidine groups). Plaque and gingival indices were used to evaluate baseline and follow-up plaque and gingivitis. Results: A total of 57 children completed the study. Both chlorhexidine and triphala groups showed significantly lower mean gingival and plaque index scores at follow up than baseline (P < 0.001). There was no significant difference in the percentage change in the mean gingival index between the two groups (P = 0.826). The percentage change in the mean plaque index was significantly higher in the chlorhexidine group compared to the triphala group (P = 0.048). Conclusion: The effectiveness of triphala in the reduction of plaque and gingivitis was comparable to chlorhexidine, and can be used for short-term purposes without potential side-effects. It is a cost-effective alternative in reducing plaque and gingivitis.
Introduction Oral health has a major influence on one’s general and oral health-related quality of life and well-being.1 Several systemic diseases have been recently linked to poor oral health. Chemical methods, as well as mechanical plaque control, play a pivotal and adjunct role in the maintenance of oral hygiene. The incorporation of broadspectrum antimicrobial mouth rinses as adjuncts to an individual’s daily oral hygiene regimens has assumed greater importance. This is because most individuals are unable to consistently maintain adequate levels of plaque control using mechanical methods alone.2,3 Loe and Schiott4 used an experimental model for gingivitis, and demonstrated that, in the absence of other oral hygiene procedures, 0.2% chlorhexidine can effectively prevent plaque and gingivitis. Subsequently, many ª 2014 Wiley Publishing Asia Pty Ltd
studies have reported similar results, which has led to the widespread use of chlorhexidine mouth rinse in clinical practice.5,6 Because of certain side-effects associated with this agent, in particular, tooth staining, increased propensity to calculus formation, and taste aberrations, a lower concentration of this agent has been recommended when used over prolonged periods.7 Studies conducted with lower concentrations (i.e. 0.1% and 0.12%) have also demonstrated equal effectiveness, as compared to 0.2% chlorhexidine.5,8 Because of its effectiveness in maintaining oral health at various concentrations, chlorhexidine remains a gold standard in oral health-care products. Herbal extracts have also been used for centuries to improve dental health and to maintain oral hygiene. Neem, miswak, lemongrass, and triphala herbal extracts have been previously for their effectiveness with respect 1
R. Bhattacharjee et al.
Efficacy of triphala mouth rinse
to plaque, gingivitis, and bacterial counts.9–13 Triphala is a well-known ancient Ayurvedic Indian powdered preparation, and has been traditionally used as a laxative in chronic constipation, indigestion, hypertension, serum cholesterol reduction, poor liver function, and ulcerative colitis.14 Scientific studies carried out in the past two decades have validated many ethnomedicinal claims, and have showed triphala to possess free-radical-scavenging, antioxidant, anti-inflammatory, antipyretic, analgesic, antibacterial, antimutagenic, wound-healing, anticariogenic, antistress, adaptogenic, hypoglycemic, anticancer, chemoprotective, radioprotective, and chemopreventive effects.15 Triphala alcohol extracts, which are used as mouth rinse, have been shown to be effective against plaque, gingivitis, and dental caries in a large-scale, 1-year follow-up study conducted among Indian children.13 Maurya et al.16 reported on the relief experienced by patients with various periodontal symptoms after using triphala mouth rinse. Similarly, Desai et al.17 reported that, in their study, triphala mouth rinse was found to have a significant reduction in periodontal indices when used in conjunction with scaling and root planing (SRP) compared to SRP alone. Narayan and Mendon18 recently reported the antiplaque efficacy of triphala, and found it to be similar to that of chlorhexidine. The potential moderating role of alcohol on plaque and gingivitis using such preparations cannot be ruled out. The concentration of alcohol is more than 20% in essential oil mouthwash, sufficient to dissolve the constituents used in the preparation, but not enough to carry out a direct antibacterial effect. Although alcohol in mouthwash is not therapeutically active, it has been shown to have multiple other effects, many of which are not beneficial and are unnecessary for the user. These range from a characteristic burning sensation upon contact with the oral mucosa, astringent action, decreased salivary flow, and atrophic changes in oral mucosa.19 The use of alcohol in mouthwashes, such as its effects on the surfaces of composite restorations,20 and its possible role in the formation of oropharyngeal cancer, is still controversial.21,22 Although a direct correlation of the cause and effect between the occurrence of oropharyngeal cancer and the use of mouthwashes with alcohol has not demonstrated to date, it has been suggested that alcohol use in daily mouth rinses, especially for children, be eliminated.23 The short-term effectiveness of triphala mouth rinse on plaque and gingivitis has not been reported in any previous studies. Thus, in the present study, we aimed to evaluate the short-term efficacy of 0.6% triphala (aqueous extract) on plaque and gingivitis levels among a sample of school children. 2
Materials and methods A randomized and double-blinded study design was used to compare the effectiveness of the aqueous extract preparation of 0.6% triphala with 0.12% chlorhexidine (Pharmacy-dispensing wing, Kasturba Hospital, Manipal, India) on plaque and gingivitis. Triphala mouth rinse consisted a combination of extracts of three fruits: Emblica officinalis, Terminalia bellirica, and Terminalia chebula. The aqueous triphala mouth rinse (0.6%) was prepared indigenously in collaboration with Sami Labs, Bangalore, India. The procedural steps involved in the mouth rinse preparation are illustrated in Figure 1. The protocol was approved by the University Ethics Committee at Manipal University, Manipal, India, and the participants’ parents gave informed consent prior to their participation. Inclusion criteria were children aged between 8 and 12 years, those willing to participate with parental consent, and a plaque index score of a minimum 0.9 (fair category of plaque index).24 Participants who were hypersensitive to oral products, had a history of recent use of broad-spectrum antibiotics, systemic illness, were unable to comply with rinsing instructions (e.g. comprehension issues), or had oral prostheses or rampant caries were excluded from participating in the study. Children with mixed dentition were selected, as there would be higher plaque accumulation.
Figure 1. Steps used in the preparation of the 0.6% triphala mouth rinse.
ª 2014 Wiley Publishing Asia Pty Ltd
R. Bhattacharjee et al.
Eligible participants were randomly assigned to one of the two treatment groups. Randomization was done by lottery method; the participants were selected after being given a numbered token that corresponded to the numbers on the mouth rinse bottles. After briefing the participants about the purpose of the study, rinsing instructions were given. The participants were divided into two groups, were provided with the assigned products (either of the mouth rinse bottles), and were asked to rinse for a minimum of 30 sec, twice a day, for 2 weeks (Figure 2). Keijser et al. and Van der Weijden et al. concluded that 30 sec of rinsing time was effective for both 0.12% and 0.2% chlorhexidine.25,26 In their study, Bonesvoll et al. showed the rapid binding of chlorhexidine in the mouth during the first 15 sec of rinsing. When compared with a 60 sec rinse, approximately half of the chlorhexidine was retained after the first 15 sec, and 75% within 30 sec.27 Thus, in our study we used a 30 sec rinsing protocol as standard. Both mouth rinses were dispensed in identical bottles, and delivered by a person not involved in the examination. All investigators and participants were unaware of the identity of the mouth rinses given. The identity of the mouth rinse bottles was revealed only after statistical analysis. The participants were given a printed timetable for 2 weeks, and were asked to put a check mark on the form after rinsing to demonstrate compliance of the instructions given. The timetable had details of time of rinsing and duration, which were entered by the parent. These instructions were given after informed consent was obtained from the parents.
Efficacy of triphala mouth rinse
The assessment of plaque and gingivitis was done using plaque and gingival indices at baseline and follow up.24,28 Calibration for clinical indices was done at the Department of Public Health Dentistry, Manipal College of Dental Sciences (Manipal, India) for 2 days. The criteria for plaque and gingival indices were discussed and implemented by senior faculty member on the participants. This was followed by an independent recording of the indices by one of the examiners (RB). These recordings were verified by the senior faculty member. Intra-examiner reliability was assessed by Pearson correlation coefficients, which were 0.94 and 0.96 for the plaque and gingival indices, respectively. Full mouth indices were recorded by a trained and calibrated examiner (RB) under artificial lighting, in a closed room on the school premises. A trained recorder (NGK) assisted the examiner in scoring the clinical indices. Statistical analysis The sample size was calculated using a power calculator, and it was determined that ≥30 participants were necessary so that there was a 20% reduction in parameter (hypothesis of plaque reduction tests compared to control), with a 10% standard deviation and a power of ≥80%.29 Data were analyzed using SPSS version 17 (SPSS, Chicago, IL, USA). A P-value of
ORIGINAL ARTICLE Community Dentistry and Oral Epidemiology
Efficacy of triphala mouth rinse (aqueous extracts) on dental plaque and gingivitis in children Ritesh Bhattacharjee1, Sridhar Nekkanti2, Nikesh G. Kumar1, Ketan Kapuria1, Shashidhar Acharya1 & Kalyana C. Pentapati1 1 Department of Public Health Dentistry, Manipal College of Dental Sciences, Manipal University, Manipal, Karnataka, India 2 Department of Pedodontics and Preventive Dentistry, Manipal College of Dental Sciences, Manipal University, Manipal, Karnataka, India
Keywords chlorhexidine, gingivitis, herbal, plaque, triphala. Correspondence Assistant Professor K. C. Pentapati, Department of Public Health Dentistry, Manipal College of Dental Sciences, Madhav Nagar, Manipal University, Manipal, Karnataka 576104, India. Tel: +91-99160-36303 Email: [email protected] Received 15 February 2013; accepted 14 January 2014. doi: 10.1111/jicd.12094
Abstract Aim: The aim of the present study was to evaluate the efficacy of triphala mouth rinse (aqueous) in the reduction of plaque and gingivitis among children. Methods: The study was a randomized, double-blinded, controlled trial, with a total of 60 school children (n = 30 in each group; triphala and chlorhexidine groups). Plaque and gingival indices were used to evaluate baseline and follow-up plaque and gingivitis. Results: A total of 57 children completed the study. Both chlorhexidine and triphala groups showed significantly lower mean gingival and plaque index scores at follow up than baseline (P < 0.001). There was no significant difference in the percentage change in the mean gingival index between the two groups (P = 0.826). The percentage change in the mean plaque index was significantly higher in the chlorhexidine group compared to the triphala group (P = 0.048). Conclusion: The effectiveness of triphala in the reduction of plaque and gingivitis was comparable to chlorhexidine, and can be used for short-term purposes without potential side-effects. It is a cost-effective alternative in reducing plaque and gingivitis.
Introduction Oral health has a major influence on one’s general and oral health-related quality of life and well-being.1 Several systemic diseases have been recently linked to poor oral health. Chemical methods, as well as mechanical plaque control, play a pivotal and adjunct role in the maintenance of oral hygiene. The incorporation of broadspectrum antimicrobial mouth rinses as adjuncts to an individual’s daily oral hygiene regimens has assumed greater importance. This is because most individuals are unable to consistently maintain adequate levels of plaque control using mechanical methods alone.2,3 Loe and Schiott4 used an experimental model for gingivitis, and demonstrated that, in the absence of other oral hygiene procedures, 0.2% chlorhexidine can effectively prevent plaque and gingivitis. Subsequently, many ª 2014 Wiley Publishing Asia Pty Ltd
studies have reported similar results, which has led to the widespread use of chlorhexidine mouth rinse in clinical practice.5,6 Because of certain side-effects associated with this agent, in particular, tooth staining, increased propensity to calculus formation, and taste aberrations, a lower concentration of this agent has been recommended when used over prolonged periods.7 Studies conducted with lower concentrations (i.e. 0.1% and 0.12%) have also demonstrated equal effectiveness, as compared to 0.2% chlorhexidine.5,8 Because of its effectiveness in maintaining oral health at various concentrations, chlorhexidine remains a gold standard in oral health-care products. Herbal extracts have also been used for centuries to improve dental health and to maintain oral hygiene. Neem, miswak, lemongrass, and triphala herbal extracts have been previously for their effectiveness with respect 1
R. Bhattacharjee et al.
Efficacy of triphala mouth rinse
to plaque, gingivitis, and bacterial counts.9–13 Triphala is a well-known ancient Ayurvedic Indian powdered preparation, and has been traditionally used as a laxative in chronic constipation, indigestion, hypertension, serum cholesterol reduction, poor liver function, and ulcerative colitis.14 Scientific studies carried out in the past two decades have validated many ethnomedicinal claims, and have showed triphala to possess free-radical-scavenging, antioxidant, anti-inflammatory, antipyretic, analgesic, antibacterial, antimutagenic, wound-healing, anticariogenic, antistress, adaptogenic, hypoglycemic, anticancer, chemoprotective, radioprotective, and chemopreventive effects.15 Triphala alcohol extracts, which are used as mouth rinse, have been shown to be effective against plaque, gingivitis, and dental caries in a large-scale, 1-year follow-up study conducted among Indian children.13 Maurya et al.16 reported on the relief experienced by patients with various periodontal symptoms after using triphala mouth rinse. Similarly, Desai et al.17 reported that, in their study, triphala mouth rinse was found to have a significant reduction in periodontal indices when used in conjunction with scaling and root planing (SRP) compared to SRP alone. Narayan and Mendon18 recently reported the antiplaque efficacy of triphala, and found it to be similar to that of chlorhexidine. The potential moderating role of alcohol on plaque and gingivitis using such preparations cannot be ruled out. The concentration of alcohol is more than 20% in essential oil mouthwash, sufficient to dissolve the constituents used in the preparation, but not enough to carry out a direct antibacterial effect. Although alcohol in mouthwash is not therapeutically active, it has been shown to have multiple other effects, many of which are not beneficial and are unnecessary for the user. These range from a characteristic burning sensation upon contact with the oral mucosa, astringent action, decreased salivary flow, and atrophic changes in oral mucosa.19 The use of alcohol in mouthwashes, such as its effects on the surfaces of composite restorations,20 and its possible role in the formation of oropharyngeal cancer, is still controversial.21,22 Although a direct correlation of the cause and effect between the occurrence of oropharyngeal cancer and the use of mouthwashes with alcohol has not demonstrated to date, it has been suggested that alcohol use in daily mouth rinses, especially for children, be eliminated.23 The short-term effectiveness of triphala mouth rinse on plaque and gingivitis has not been reported in any previous studies. Thus, in the present study, we aimed to evaluate the short-term efficacy of 0.6% triphala (aqueous extract) on plaque and gingivitis levels among a sample of school children. 2
Materials and methods A randomized and double-blinded study design was used to compare the effectiveness of the aqueous extract preparation of 0.6% triphala with 0.12% chlorhexidine (Pharmacy-dispensing wing, Kasturba Hospital, Manipal, India) on plaque and gingivitis. Triphala mouth rinse consisted a combination of extracts of three fruits: Emblica officinalis, Terminalia bellirica, and Terminalia chebula. The aqueous triphala mouth rinse (0.6%) was prepared indigenously in collaboration with Sami Labs, Bangalore, India. The procedural steps involved in the mouth rinse preparation are illustrated in Figure 1. The protocol was approved by the University Ethics Committee at Manipal University, Manipal, India, and the participants’ parents gave informed consent prior to their participation. Inclusion criteria were children aged between 8 and 12 years, those willing to participate with parental consent, and a plaque index score of a minimum 0.9 (fair category of plaque index).24 Participants who were hypersensitive to oral products, had a history of recent use of broad-spectrum antibiotics, systemic illness, were unable to comply with rinsing instructions (e.g. comprehension issues), or had oral prostheses or rampant caries were excluded from participating in the study. Children with mixed dentition were selected, as there would be higher plaque accumulation.
Figure 1. Steps used in the preparation of the 0.6% triphala mouth rinse.
ª 2014 Wiley Publishing Asia Pty Ltd
R. Bhattacharjee et al.
Eligible participants were randomly assigned to one of the two treatment groups. Randomization was done by lottery method; the participants were selected after being given a numbered token that corresponded to the numbers on the mouth rinse bottles. After briefing the participants about the purpose of the study, rinsing instructions were given. The participants were divided into two groups, were provided with the assigned products (either of the mouth rinse bottles), and were asked to rinse for a minimum of 30 sec, twice a day, for 2 weeks (Figure 2). Keijser et al. and Van der Weijden et al. concluded that 30 sec of rinsing time was effective for both 0.12% and 0.2% chlorhexidine.25,26 In their study, Bonesvoll et al. showed the rapid binding of chlorhexidine in the mouth during the first 15 sec of rinsing. When compared with a 60 sec rinse, approximately half of the chlorhexidine was retained after the first 15 sec, and 75% within 30 sec.27 Thus, in our study we used a 30 sec rinsing protocol as standard. Both mouth rinses were dispensed in identical bottles, and delivered by a person not involved in the examination. All investigators and participants were unaware of the identity of the mouth rinses given. The identity of the mouth rinse bottles was revealed only after statistical analysis. The participants were given a printed timetable for 2 weeks, and were asked to put a check mark on the form after rinsing to demonstrate compliance of the instructions given. The timetable had details of time of rinsing and duration, which were entered by the parent. These instructions were given after informed consent was obtained from the parents.
Efficacy of triphala mouth rinse
The assessment of plaque and gingivitis was done using plaque and gingival indices at baseline and follow up.24,28 Calibration for clinical indices was done at the Department of Public Health Dentistry, Manipal College of Dental Sciences (Manipal, India) for 2 days. The criteria for plaque and gingival indices were discussed and implemented by senior faculty member on the participants. This was followed by an independent recording of the indices by one of the examiners (RB). These recordings were verified by the senior faculty member. Intra-examiner reliability was assessed by Pearson correlation coefficients, which were 0.94 and 0.96 for the plaque and gingival indices, respectively. Full mouth indices were recorded by a trained and calibrated examiner (RB) under artificial lighting, in a closed room on the school premises. A trained recorder (NGK) assisted the examiner in scoring the clinical indices. Statistical analysis The sample size was calculated using a power calculator, and it was determined that ≥30 participants were necessary so that there was a 20% reduction in parameter (hypothesis of plaque reduction tests compared to control), with a 10% standard deviation and a power of ≥80%.29 Data were analyzed using SPSS version 17 (SPSS, Chicago, IL, USA). A P-value of
