Are herbal mouthwash efficacious over chlorhexidine on the dental plaque?

Abstract

To compare the effect of herbal extract mouthwash and chlorhexidine mouthwash on the dental plaque level.
The subjects (60 healthy medical students aged ranges between 20 and 25 years) were randomly divided into two groups, that is, the herbal group and the chlorhexidine gluconate mouthwash group. The data were collected at the baseline and 3 days. The plaque was disclosed using erythrosine disclosing agent and their scores were recorded using the Quigley and Hein plaque index modified by Turesky-Gilmore-Glickman. Statistical analysis was carried out later to compare the effect of all the two groups.
Our result showed that the chlorhexidine group shows a greater decrease in plaque score followed by herbal extract, but the result was statistically insignificant.
The results indicate that herbal mouthwash may prove to be an effective agent owing to its ability to reduce plaque level, especially in low socioeconomic strata.

Full text

Pharmacognosy Research | July-September 2015 | Vol 7 | Issue 3 277
Address for correspondence:
Dr. Devanand Gupta, Assistant Professor, Department of Public
health Dentistry, Institute of Dental Science, Bareilly,
Uttar Pradesh, India.
E-mail: drdevanandgupta@aol.com
INTRODUCTION
Oral diseases have a strong history of treating by natural
remedies. Dental caries and periodontal diseases are essentially
caused by the micro-organisms present in dental plaque.
Research has linked these micro-organisms, particularly those
with adherent biolm properties, to clinically specic oral
conditions, such as caries, periodontal disease and halitosis.[1]
Individual’s susceptibility to dental and periodontal disease
is dependent on a complex combination of risk factors;
including genetics, systemic factors, diet and oral hygiene.
Clinical control of these diseases can most readily be achieved
by reducing the oral microbial load of the plaque biolm.
Plaque reduction has been the hallmark of preventive
dentistry since the advent of antibiotics and the realization
that bacteria are possible causative agents of the major dental
diseases, caries and periodontal disease.[2]
Both chemical and mechanical oral hygiene aids are used for
removal and prevention of plaque. Mechanical plaque control
measures, such as toothbrushes, dental oss, toothpicks, and
interdental brushes are very popular and are mostly used in
conjunction with chemical plaque control aids. Even though,
the toothbrush is the most widely used oral hygiene aid, a
majority of the population is not able to perform mechanical
plaque removal effectively. Hence, there is the need for chemical
plaque control. Chemical methods of reducing plaque, such
as mouthwashes, are therefore appealing as they can provide
signicant benets to patients who cannot maintain adequate
mechanical plaque control. They can be considered a less
technically demanding adjuvant to mechanical control.
From the earliest times, plants have not only provided food,
cosmetics and embalming ointments, but also a plethora
of easily available remedies for the maladies of humanity.[3]
Plants have been exploited by humans for many centuries as
sources of medicinal drugs, due to the presence of various
bioactive compounds. As the popularity of these herbal
products continues to rise, dental professionals are expected
to provide information to patients about these products’
Aim: To compare the effect of herbal extract mouthwash and chlorhexidine mouthwash
on the dental plaque level. Materials and Methods: The subjects (60 healthy medical
students aged ranges between 20 and 25 years) were randomly divided into two groups,
that is, the herbal group and the chlorhexidine gluconate mouthwash group. The data were
collected at the baseline and 3 days. The plaque was disclosed using erythrosine disclosing
agent and their scores were recorded using the Quigley and Hein plaque index modied by
Turesky-Gilmore-Glickman. Statistical analysis was carried out later to compare the effect of
all the two groups. Results: Our result showed that the chlorhexidine group shows a greater
decrease in plaque score followed by herbal extract, but the result was statistically insignicant.
Conclusion: The results indicate that herbal mouthwash may prove to be an effective agent
owing to its ability to reduce plaque level, especially in low socioeconomic strata.
Key words: Chlorhexidine, herbal mouthwash, holistic dentistry, plaque index
PHCOG RES.ORIGINAL ARTICLEORIGINAL ARTICLE
PHCOG RES.
Are herbal mouthwash efcacious over chlorhexidine on
the dental plaque?
Devanand Gupta1,2, Swapna Nayan3, Harshad K. Tippanawar4, Gaurav I. Patil5, Ankita Jain6,
Rizwan K. Momin7, Rajendra Kumar Gupta8
1Department of Public Health Dentistry, Institute of Dental Science, Bareilly, Uttar Pradesh, 2General Secretary, International Society for
Holistic Dentistry, Uttrakhand, 3Department of Oral and Maxillofacial Surgery, D.Y Patil Dental College, Nerul, Navi Mumbai, Maharashtra,
4Departments of Conservative, Endodontics and Esthetics Dentistry, 5Orthodontics and Dentofacial Orthopaedics, JSS Dental College
and Hospital, Mysore, 6Department of Public Health Dentistry, Teerthanker Mahaveer Dental College and Research Centre, Moradabad,
7Department of Oral Pathology, Jaipur Dental College, Jaipur, 8Principal, Government Degree college, Banbasa, Uttrakhand, India
Submitted: 18-03-2015 Revised: 23-03-2015 Published: 02-06-2015
ABSTRACT
Access this article online
Website:
www.phcogres.com
DOI: 10.4103/0974-8490.155874
Quick Response Code:

Gupta, et al.: Herbal mouthwash and dental plaque
278 Pharmacognosy Research | July-September 2015 | Vol 7 | Issue 3
safety and efcacy. This can be difcult, however, owing to
a lack of professional consensus on the subject. Until today,
an insufcient amount of clinical research on herb-based
mouthrinses and dentifrices has been reported in Asia,
especially in India and other southeast Asian countries (where
these products are most popular and widely used).
Various mouth rinses are available in the market, amongst
which Chlorhexidine is the most popular. It is recognized
as the primary agent for chemical plaque control, its clinical
efcacy being well known to the profession. It has also been
recognized by the pharmaceutical industry as the positive
control against which the efcacy of alternative antiplaque
agents should be measured, and has earned its eponym of
gold standard. But it cannot be used on a long term basis
because of various side effects like brown discoloration, taste
perturbation, oral mucosal lesions, parotid swelling, enhanced
supragingival plaque formation and sometimes unacceptable
taste.[4,5] An effective alternative to Chlorhexidine with all
the good qualities and sans its unpleasant effects is highly
desirable and has been long awaited. Herbal mouthwash
may act as a good and cost-effective oral hygiene product.
The history of drug development has its foundation
rmly set in the study of natural remedies used to treat
human disease over centuries. Many studies have found
that Cinnamon and Terminalia chebula have antibacterial
and antifungal properties.[6,7] However, no study had been
conducted to check the antiplaque properties of Cinnamon
and T. chebula extract in combination. Hence, the present
study has been conducted to check the effect of this
combination on the clinical level of dental plaque.
MATERIALS AND METHODS
This double-blind randomized control trial was conducted
in the department of public health dentistry on volunteered
university students of Teerthanker Mahaveer University.
All subjects signed an Institutional Review Board approved
consent form.
Inclusion and exclusion criteria
The students with no history of any dental treatment,
antibiotic or anti-inammatory drug therapy for the past
3 months were included in the study. Those volunteers who
had used antibiotics or mouthwash for 5 consecutive days or
corticosteroids in the past 30 days were excluded from the
study. Furthermore, those who had undergone professional
measures to remove plaque and calculus in the past 15 days,
and did not give consent for the clinical trial were excluded.
Sample size and randomization
A sampling frame (n = 60) was prepared from the students
of Teerthankar Mahaveer University of those who fullled
the inclusion and exclusion criteria. A total of 60 volunteers
were randomly allocated into the two study groups through
computer-generated random numbers. Random allocation
of mouth rinses using the lottery method was done.
Group 1 (n = 30) was given herbal mouthwash (combination
of Cinnamon and T. chebula extract mouthwash) and
instructed to use 10 ml twice a day for 3 days.
Group 2 (n = 30) was given chlorhexidine (.12%) and
instructed to use 10 ml twice a day for 3 days.
Herbal mouthwash composed of 50% concentration of
T. chebula and remaining 50% was the Cinnamon extract. All
the students were subjected to scaling and polishing to get
the baseline score to nil. All the two groups followed same
oral hygiene instructions, except for the use of allocated
mouthrinse. Both the mouthrinse were made identical.
This was done with the help of Department of Pharmacy,
TMU. Students in all the two groups were instructed to
rinse their mouth with 10 ml of mouthwash twice daily
after breakfast and other after lunch for 3 days for 1 min
and not to rinse with water thereafter.
The data were collected at the end of 3rd day. The plaque
was disclosed using erythrosine disclosing agent and their
scores were recorded per tooth using the Quigley and Hein
plaque index modied by Turesky-Gilmore-Glickman.[8]
A single examiner, who was trained and calibrated to record
the plaque and gingival scores, recorded the ndings at all
two intervals and for both the groups. The recorder was
blinded to the type of the mouthwash used by participants.
Statistical analysis
The data were analyzed using SPSS version 17. ANOVA
followed by post‑hoc least signicant difference (LSD) were
used for analysis. P value of 0.05 was taken to be signicant.
RESULTS
There were no reports of adverse reactions to any of
the mouth rinses used. ANOVA was used to analyze
the reduction in plaque in the two groups. A signicant
decrease was noted in the plaque in both the herbal
and chlorhexidine groups at 3 days (P < 0.05). There
was a progressive decrease in the plaque at 5% level of
significance. Chlorhexidine group showed maximum
decease when compared to the herbal group, but it was
not statistically signicant. Multiple comparisons were
obtained by post‑hoc LSD. The difference in the decrease
in plaque (P = 0.309 at 3 days) between herbal group and
chlorhexidine group was not statistically signicant. Data
show that there was no signicant difference between

Gupta, et al.: Herbal mouthwash and dental plaque
Pharmacognosy Research | July-September 2015 | Vol 7 | Issue 3 279
herbal-based mouth rinse and chlorhexidine for any clinical
parameters throughout the study.
DISCUSSION
It is generally accepted that the formation of dental
plaque at the tooth/gingiva interface is one of the major
causes of gingival inammation and caries. The single
best way to remove harmful plaque from teeth is to brush
teeth regularly and appropriately. Brushing teeth with
toothpaste helps to remove plaque, resist decay, promote
remineralization, polish and remove stains, etc. There is
an increase in the use of mechanical and chemical plaque
control agents to prevent dental caries and periodontal
disease. Some of the methods are proper and regular
tooth-brushing, ossing and rinsing with mouthwashes.
Various chemical mouthwashes are available in the
market, but are associated with side-effects such as
immediate hypersensitivity reactions, toxicity, tooth
staining, etc., Alternative medicines may be developed
from medicinal plants as these plants contain natural
phytochemicals, and hence, can replace synthetic drugs.
T. chebula is rightly called the ‘King of Medicines’ in Tibet
and is always listed rst in Ayurvedic Materia Medica
in India. T. chebula fruit has been used as a traditional
medicine against various human ailments since antiquity.
It exerts a wide range of pharmacological effects. Animal
studies have also shown that it exerts anticarcinogenic
and antimutagenic effects. In addition, it exerts
cardioprotective, hepatoprotective and radioprotective
effects.[9] Cinnamon (Cinnamomum zeylanicum) is
one of the herb which has been used extensively for
treatment of several conditions including general and
oral health. In traditional medicine cinnamon is used for
colds, atulence, nausea and diarrhea. It’s also believed
to improve energy, vitality, and circulation. Studies
have found that cinnamon may have antibacterial and
antifungal properties.
Two studies have claimed T. chebula as an antiplaque
agent.[9,10] However, until date, a comparison of the
clinical antiplaque effectiveness of the combination of
T. chebula with Cinnamon and 0.12% chlorhexidine has
not been reported in controlled trials. As far as we know,
this is the rst published trial that directly compared
the antiplaque efcacy of combination of T. chebula and
Cinnamon extract mouthwash and chlorhexidine rinses,
which limits the possibility of comparison with the
literature.
Terminalia chebula extracts exerts antibacterial, antiviral
effect against Helicobactor pylori, Xanthomonas campestris
pv. citri and Salmonella typhi, herpes simplex virus type-1,
human immunodeficiency virus-1 and Cytomegalovirus.
T. chebula contains almost 30% tannins and other minor
constituents are polyphenols such as corilagin, galloyl
glucose, punicalagin, terflavin A and maslinic acid.
Tannins are a group of polymeric phenolic substances
of pyrogallol (hydrolysable) types, releasing gallic acid
as a main component, which is well recognized for its
antimicrobial and astringent property.[9]
According to Ooi et al.[7] Cinnamon is active on Gram-positive
and Gram-negative bacteria. Cinnamaldehyde is the major
and active component in Cinnamon.[11]
The in vitro study conducted by Fani, Kohanteb showed that
Cinnamon oil showed strong, promising inhibitory activity
on all the Streptococcus mutans isolates at a concentration
of as low as 3.12%.[12] T. chebula alone may also act as an
antiplaque agent.[10]
Mechanisms where by cinnamon extract inhibit growth
of bacteria especially against oral bacteria are still
unclear, most explanations concerning the antibacterial
effect of cinnamon in general related the inhibitory
effect of cinnamon to its essential oils. An important
characteristic of essential oils and their components is
their hydrophobicity, which enable them to partition the
lipids of the bacterial cell membrane, disturbing the cell
structures and rendering them more permeable. Extensive
leakage from bacterial cells or the exit of critical molecules
and ions will lead to death.[13]
Most of the studies on Cinnamon oil suggest that it is not
harmful and may be used as an agent to inhibit the growth
of bacteria, fungi, and yeast. However, some cases of
contact dermatitis and stomatitis associated with Cinnamon
oil have been reported.[14] Cinnamon is rarely associated with
allergic reactions with symptoms like localized burning
sensation, sloughing, erythema.[14]
In the present study, combination of T. chebula and Cinnamon
was used. 50% T. chebula extract and 50% Cinnamon was used
to make the mouthwash, which acted as antiplaque agent.
The efcacy of combination of cinnamon and T. chebula has
never been tested on the dental plaque level. No studies
had been conducted to show the effect of combination
of Cinnamon and T. chebula extract on plaque which is the
main precursor of periodontal diseases.
In the present study, there was a signicant difference
on the clinical level of dental plaque in both herbal and
chlorhexidine mouthwash group before and after the
experimental period. Chlorhexidine shows more reduction

Gupta, et al.: Herbal mouthwash and dental plaque
280 Pharmacognosy Research | July-September 2015 | Vol 7 | Issue 3
in dental plaque than herbal extract, but the result was
statistically insignicant. The results of these two groups
on plaque could not be compared with other studies as no
studies have been reported in the literature, which has tried
to assess the same effect. Thus it can be said that the holistic
or complementary medicine has a great potential which
can be utilized for the better oral and general health.[15-30]
Limitations
Present study was a short term study employing a crude
extract of T. chebula and Cinnamon as mouthrinse. Though
signicant results were obtained at 3 days in the herbal
groups, long term clinical efcacy (6 months –as prescribed
by ADA)[31] and adverse effects associated with long term
usage could not be assessed. Microbiological assessment on
plaque or saliva of the participants was not performed and
hence this study could not provide any evidence regarding
the effects of these mouthwashes on oral microbial ora.
CONCLUSION
Within the limitation of this trial, herbal mouthwash has
been shown to demonstrate similar effects on a plaque as
compared to the standard drug chlorhexidine. Further,
long term research needs to be done to check the efcacy
and effectiveness of herbal products over standard drug
regime. Given the increasing trend in Ayurveda use in day
today life and the enormous power to two contemporary
approaches – evidence-based clinical practice and modern
dentistry – the time is ripe to reformulate our approach
to the practice, research and training in Ayurveda and
holistic dentistry. Natural compounds can again become
central players in the treatment of disease and in the
understanding of disease mechanisms.
REFERENCES
1. Marsh PD. Dental plaque as a biolm: The signicance
of pH in health and caries. Compend Contin Educ Dent
2009;30:76-8, 80, 83.
2. Barnett ML. The rationale for the daily use of an antimicrobial
mouth rinse. J Am Dent Assoc 2006;137:16S-21.
3. Smith G. Herbs in Medicine [review]. Triple Helix; 2004. p. 12-13.
Available from: http://www.admin.cmf.org.uk/pdf/helix/aut04/29
herbs.pdf. [Last accessed on 2 Jan 2015].
4. Ceylane A, Daniel Y. Antimicrobial activity of spices. J Rapid
Methods Autom Microbiol 2004;12:1-55.
5. Rashad JM. Effect of water cinnamon extract on mutans
streptococci, in comparison to chlorhexidine gluconate and
zac (in vitro and in vivo study). Mustansiria Dent J 2008;5:250-60.
6. Rani P, Khullar N. Antimicrobial evaluation of some medicinal
plants for their anti-enteric potential against multi-drug resistant
Salmonella typhi. Phytother Res 2004;18:670-3.
7. Ooi LS, Li Y, Kam SL, Wang H, Wong EY, Ooi VE. Antimicrobial
activities of cinnamon oil and cinnamaldehyde from the Chinese
medicinal herb Cinnamomum cassia Blume. Am J Chin Med
2006;34:511-22.
8. Turesky S, Gilmore ND, Glickman I. Reduced plaque formation
by the chloromethyl analogue of victamine C. J Periodontol
1970;41:41-3.
9. Gupta D, Bhaskar DJ, Gupta RK, Karim B, Gupta V,
Punia H, et al. Effect of Terminalia chebula extract and
chlorhexidine on salivary pH and periodontal health: 2 weeks
randomized control trial. Phytother Res 2014;28:992-8.
10. Gupta D, Gupta RK, Bhaskar DJ, Gupta V. Comparative
Evaluation of Terminalia chebula Extract Mouthwash and
chlorhexidine Mouthwash on Plaque and Gingival In
ammation – 4-week Randomised Control Trial. Oral Health Prev
Dent 2015;13:5-12.
11. Burt S. Essential oils: Their antibacterial properties and
potential applications in foods – A review. Int J Food Microbiol
2004;94:223-53.
12. Fani MM, Kohanteb J. Inhibitory activity of Cinnamon zeylanicum
and Eucalyptus globulus oils on Streptococcus Mutans,
Staphylococcus aureus, and Candida species isolated from
patients with oral infections. Shiraz Univ Dent J 2011;11:14-22.
13. Kwon, J, Yu A, and. Park H. Bactericidal effects and inhibition of
cell separation of cinnamic aldehyde on Bacillus cereus Bacillus
cereus. Lett. Appl. Microbiol 2003; 37:61-65.
14. Gupta C, Kumari A, Garg AP, Catanzaro R, Marotta F.
Comparative study of cinnamon oil and clove oil on some oral
microbiota. Acta Biomed 2011;82:197-9.
15. Gupta D, Dalai DR, Swapnadeep, Mehta P, Indra BN, Rastogi S,
Jain A et al. Acupuncture (zhēn jiǔ) ‑ an emerging adjunct in
routine oral care. J Tradit Complement Med 2014;4:218-23.
16. Gupta RK, Gupta D, Bhaskar DJ, Yadav A, Obaid K, Mishra S.
Preliminary antiplaque efcacy of aloe vera mouthwash on 4
day plaque re-growth model: randomized control trial. Ethiop J
Health Sci 2014;24:139-44.
17. Gupta D, Bhaskar DJ, Gupta KR, Karim B, Kanwar A, Jain A et al.
Use of complementary and alternative medicine for work related
musculoskeletal disorders associated with job contentment
in dental professionals: Indian outlook. Ethiop J Health Sci
2014;24:117-24.
18. Gupta D, Bhaskar DJ, Gupta RK, Jain A, Yadav P, Dalai DR
et al. Is complementary and alternative medicine effective in job
satisfaction among dentists with musculoskeletal disorders?A
cross sectional study. Med Pr 2014;65:317-23.
19. Gupta D, Batra R, Mahajan S, Bhaskar DJ, Jain A, Shiju M
et al. Comparative Evaluation of the Complementary and
Alternative Medicine Therapy and Conventional Therapy Use
for Musculoskeletal Disorders Management and Its Association
with Job Satisfaction among Dentists of West India. J Tradit
Complement Med 2014;4:218-23.
20. Ravneet Kaur Randhawa, Nidhi Gupta, Vikram Arora, Preety
Gupta. Antioxidants in oral health. Int J Contemp Med Res
2015;2:53-8.
21. Saloni Sood, Manish Bhargava, Pallvi Rathore. Diabetes
Mellitus Leading Expiry of Oral Health. Int J Contemp Med Res
2015;2:100-4.
22. Pradeep Raghav, Swati Jain, Munish Reedy, Shishir Singh,
Tarun S Phull, Raj K Verma. Evaluation of nasal form in average,
pleasing and attractive looking individuals. Int J Contemp Med
Res 2015;2:12-9.
23. Megalaa N, Kayalvizhi G, Silas AJ, Sajeev R, Saravana Kumar
MS. Role of herbal leaf extracts in caries prevention. Int J
Contemp Med Res 2014;1:71-8.
24. Gupta D, Gupta RK. Investigation of antibacterial efcacy
of Acacia nilotica against salivary mutans streptococci: A
randomized control trial. Gen Dent 2015;63:23-7.

Gupta, et al.: Herbal mouthwash and dental plaque
Pharmacognosy Research | July-September 2015 | Vol 7 | Issue 3 281
Cite this article as: Gupta D, Nayan S, Tippanawar HK, Patil GI, Jain A,
Momin RK, et al.Areherbalmouthwashefcaciousoverchlorhexidineonthe
dentalplaque?.PhcogRes2015;7:277-81.
Source of Support: Nil, Conict of Interest: None declared.
25. Gupta D, Nagar P, Karim B, Khan IM, Naveen B, Chaturvedi M,
Verma R, Purwar P, Gupta RK. Tobacco abuse amongst the school
going students of 15 to 18 years of Almora district, Uttarakhand: A
cross sectional study. Oral Health Dent Manag 2014;13:680-6.
26. Gupta D, Bhaskar DJ, Gupta RK, Karim B, Jain A, Singh R,
et al. A randomized controlled clinical trial of Ocimum sanctum
and chlorhexidine mouthwash on dental plaque and gingival in
ammation. J Ayurveda Integr Med 2014d;5:109-16.
27. Gupta D, Bhaskar D.J, Gupta RK. Contemporary and alternative
dentistry: Ayurveda in dentistry. Saarbrücken: Lap Lambert
Academic Publishing, 2013:28-30.
28. Jain A, Bhaskar DJ, Gupta D, Agali C, Gupta V, Gupta RK,
Yadav P, Lavate AB, Chaturvedi M. Comparative evaluation
of honey, chlorhexidine gluconate (0.2%) and combination of
xylitol and chlorhexidine mouthwash (0.2%) on the clinical level
of dental plaque: A 30 days randomized control trial. Perspect
Clin Res 2015;6:53-7.
29. Jain A, Bhaskar DJ, Gupta D, Agali C, Gupta V, Gupta RK,
Yadav P, Lavate AB, Chaturvedi M. Comparative evaluation
of honey, chlorhexidine gluconate (0.2%) and combination of
xylitol and chlorhexidine mouthwash (0.2%) on the clinical level
of dental plaque: A 30 days randomized control trial. Perspect
Clin Res. 2015;6:53-7.
30. Oral Piercings ‑ Pain or Pleasure? Puneet Sharma, Sanjeev
Kumar Salaria, Ravi Kiran N, Shilpa Kamra, Deepak Kumar
Bansal. Int J Contemp Med Res 2015;2:93-99.
31. Council on scientic Affairs. Acceptance Program Guidelines
-Chemotherapeutic Products for Control of Gingivitis. [Internet]:
ADA; 2008 [cited 2011 25th september];Available from: http://
www.ada.org/sections/scienceAndResearch/pdfs/guide_
chemo_ging.pdf. [Last accessed on 2015 Jan 6].