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Journal of Nepalese Society of Periodontology and Oral Implantology : Vol. 1, No. 1, Jan-Jun, 2017
Effectiveness of Indigenously Prepared
Punica Granatum and Camellia Sinesis Mouthwashes as an adjunct
to Non Surgical Periodontal Therapy: A Clinical Trial
Original Article
ABSTRACT
Background: Chronic periodontitis is a bacterially induced chronic disease that is immune-inflammatory in nature. The incidence and
progression of this disease is related to a substantial increase in gram negative anaerobic rods. The use of antimicrobial mouthwashes as
an adjunct to mechanical plaque control is well established in dental practice. Punica granatum and Camellia sinesis extract are naturally
occurring antimicrobial agents. The active ingredient in Punica granatum and Camellia sinesis is polyphenolic flavonoid, which is an
antioxidant in nature. It inhibits the production of arachidonic acid metabolites such as pro- inflammatory prostaglandins and leukotriens,
resulting in a decreased inflammatory response.
Aim: To evaluate the efficacy of indigenously prepared Punica granatum and Camellia sinesis mouthwashes to the commercially available
chlorhexidine mouthwash.
Materials and Methods: Thirty subjects diagnosed with chronic generalized marginal gingivitis were selected and randomly divided into
three groups. Group 1 – Camellia sinesis mouthwash group, Group 2 – Punica granatum mouthwash group and Group 3 – Chlorhexidine
mouthwash group. Subjects were instructed to use the prescribed mouthwash for 14 days. Plaque index, gingival index and calculus
component of periodontal index were recorded at baseline and at 14 days.
Results: The clinical study observed significant improvement in plaque and gingival status at all sites (
p<
0.05). Camellia sinesis and Punica
granatum mouthwash showed significant improvement in plaque, gingival and calculus score.
Conclusion: Camellia sinesis and Punica granatum mouthwash are beneficial in improving gingival status due to its profound styptic action,
with sufficient reduction in plaque scores.
Key Words: Chlorhexidine, calculus, Camellia sinesis, gingivitis, mouthwash, plaque, Punica granatum
INTRODUCTION
In Ayurveda, dental health (dantaswasthya) is determined
by two factors, the constitution (prakriti) of each person
and the climatic changes resulting from the solar, lunar and
planetary influences (kala parinama).
1
In dental sciences, it is
Dr. Harshal Rajeshbhai Champaneri,1 Dr. Nirma Yadav,2 Dr. Barkha Makhijani,3
Dr. Neema Shetty,4 Dr. Aditi Mathur,5 Dr. Balaji Manohar6
1,2Resident, 3Senior lecturer, 4,5Reader, 6Professor and Head
Department of Periodontics, Pacific Dental College & Hospital, Udaipur, India
believed that dental plaque is the main etiological factor that
causes caries, gingivitis and periodontal disease. Although,
brushing of teeth is considered the most effective method of
cleaning the teeth and controlling plaque, mouthwashes are
widely used as adjuncts to toothbrushing and in delivering
active agents to the teeth and gums.
2
Chlorhexidine is a very
popular mouthwash that has been prescribed by clinicians.
Chlorhexidine is regarded as the ‘gold standard’ antiplaque
agent and is particularly effective against gingivitis. This
mouthwash is widely used as an adjunct in the treatment
of periodontitis. However; most practitioners do not
recommend the long-term and daily use of chlorhexidine
as a mouthwash, mainly because of its side effects, such as
objectionable taste, tooth discoloration, desquamation and
soreness of oral mucosa. The activity of this mouthwash is pH
J Nep Soc Perio Oral Implantol. 2017;1:27-31
Correspondence:
Dr. Harshal Rajeshbhai Champaneri
Department of Periodontics,
Pacific Dental College & Hospital, Udaipur, India
email: harshalcham@gmail.com
Citation
Champaneri HR, Yadav N, Makhijani B, Shetty N, Mathur A,
Manohar B. Effectiveness of indigenously prepared Punica
granatum and camellia sinesis mouthwashes as an adjunct to non
surgical periodontal therapy: a clinical trial. J Nep Soc Perio Oral
Implantol. 2017;1:27-31.
28 Journal of Nepalese Society of Periodontology and Oral Implantology : Vol. 1, No. 1, Jan-Jun, 2017
dependent and is greatly reduced in the presence of organic
matter. The side effects caused by this mouthwash limit the
acceptability by the users for the long-term use in preventive
dentistry. Manufacturers have tried to modify the taste of
the mouthwashes, but the bitter taste of chlorhexidine is
evidently difficult to mask.
2
With the continuous need to counter the adverse effects,
improve the antiplaque and antigingivitis potential and to
reduce the increasing microbial resistance to conventional
antiseptics and antibiotics, attention is now turning to the
use of natural antimicrobial compounds (herbal extracts). In
1989, a patent had been filed at the European patent office
stating that the combination of herbal extracts leads to the
synergistic reduction of both dental plaque and gingival
bleeding.
2
Herbal products are being used since ancient times for the
treatment of various ailments. Of late, the commercial use of
these products in toothpaste and for oral irrigation delivery
has increased manifold. Some of the natural or herbal
products and their extracts, such as guava, pomegranate,
neem, propolis, tulsi, green tea, cranberry and grapefruit,
when used in mouthwashes have shown significant
advantages over the chemical ones.
2
Complementary medicine received a great attention during
recent decades which recommends supplementation with
various ingredients. Diverse modes of delivery including
chewing candy, chewing gum, dentifrices and local drug
delivery strips are introduced. Tea and in particular, green tea
(Camellia sinesis) are among most popular beverages, with
high daily consumption in Asia and especially in Iran. Several
properties including antioxidant, anticaries, antibacterial,
antiviral, antidiabetic, antimutagenic and antitumoral
properties are addressed for Camellia sinesis.
3
Camellia
sinesis from the family of Thea Cease is mostly cultivated in
coasts of Caspian sea, North of Iran. Its remedial effects are
associated with the polyphenol contents comprising catechin
(C), epicatechin (EC), gallocatechin (GC), epigallocatechin
(EGC), epicatechin gallate (ECG), and epigallocatechin gallate
(EGCG). The latter two are mainly found in green tea rather
than the black tea and are amongst the most potential
contents to be reviewed for periodontal adjunct therapies in
terms of their special anti-collagenase activity.
4-6
One of the recent herbal products is Pomegranate (Punica
granatum). Punica granatum Linn belongs to family
Punicaceae, mostly known as “Punica granatum.” It is a
shrub native from Asia where several of its parts have been
used as an astringent, haemostatic and for diabetes control.
7
The genus name, Punica, was the Roman name for Carthage,
where the best Punica granatums were known to grow.
8
Punica
granatum is currently finding important applications in the
field of dental health. Clinical studies have shown that this
popular antioxidant superstar attacks the causes of tooth
decay at the biochemical level, with remarkable vigour. When
used regularly in combination with toothpaste that has been
reinforced with bioactive botanical extracts, Punica granatum
containing mouthwash may fight dental plaque and calculus
formation by inhibiting the activities of the microorganisms.
9
Sole treatment with scaling and root planing may lack
achievement in complete eradication of red complex bacteria
in deep narrow pockets, hence; adjunct chemical elimination
for plaque induced periodontal diseases seems necessary.
The aim of present study was to evaluate the effectiveness of
indigenously prepared 10% Camellia sinesis and 20% Punica
granatum mouthwash over 0.2% chlorhexidine mouthwash in
30 subjects.
The objectives were to evaluate the efficacy of 10% Camellia
sinesis mouthwash and 20% Punica granatum mouthwash
over 0.2% chlorhexidine mouthwash as an anti-plaque
agent, to evaluate the efficacy of 10% Camellia sinesis
mouthwash and 20% Punica granatum mouthwash over 0.2%
chlorhexidine mouthwash as an anti-gingivitis agent and to
evaluate the efficacy of 10% Camellia sinesis mouthwash and
20% Punica granatum mouthwash over 0.2% chlorhexidine
mouthwash on inhibition of calculus formation.
MATERIALS AND METHODS
A single blinded controlled clinical trial was conducted in
30 subjects (18 males, 12 females), aged 20-60 years who
presented with chronic generalized marginal gingivitis.
Subjects with a minimum of 20 natural teeth with a Gingival
index score (Loe and Silness) between 1.1 to 2.0, Plaque index
score (Silness and Loe) between 1.1 to 2.0, and periodontal
index (Ramjford calculus component) < 2 were included.
Subjects who had undergone periodontal therapy in the past
three months were excluded from the study.
Sample Preparation
Ten percent Camellia sinesis mouthwash: 500 g of dry green
tea leaves were soaked in 500 ml of water and 500 ml of
95.5% absolute ethanol for 3 days, and then heated to 40
o
C
until the volume was reduced to a third. Finally green tea
mouthwash 10% was prepared (10 ml of extract in 100 ml of
distilled water) and dispensed in bottles containing 250 ml.
(Figure 1)
Champaneri et al. : Effectiveness of Indigenously Prepared Punica Granatum and Camellia Sinesis Mouthwashes as An Adjunct to Non Surgical Periodontal Therapy...
29
Journal of Nepalese Society of Periodontology and Oral Implantology : Vol. 1, No. 1, Jan-Jun, 2017
20% Punica granatum mouthwash: 500 g of dry rind (peel
of pomegranate) were soaked in 500 ml of water and 500
ml of 95.5% absolute ethanol for 3 days, and then heated to
40
o
C until the volume was reduced to a third. Finally Punica
granatum mouthwash 20% was prepared (20 ml of extract in
100 ml of distilled water) and dispensed in bottles containing
250 ml. (Figure 2)
The screening and clinical examinations were carried out at
the Department of Periodontics, Pacific Dental College and
Hospital, Debari, Udaipur. All subjects signed an informed
consent form and underwent scaling and root planning.
The subjects recruited were randomly allocated into
3 groups:
Group I: 10 subjects received 10% Camellia sinesis mouthwash
to rinse twice daily for 30 seconds using 10 ml solution for
14 days.
Group II: 10 subjects received 20% Punica granatum
mouthwash to rinse twice daily for 30 seconds using 10 ml
solution for 14 days.
Group III: 10 subjects received 0.2% chlorhexidine mouthwash
to rinse twice daily for 30 seconds using 10 ml solution for
14 days.
Figure 1. 10% Camellia Sinesis Mouthwash Figure 2. 20% Punica Granatum Mouthwash Figure 3. 0.2% Chlorhexidine Mouthwash
All subjects were taught to brush their teeth twice daily by
Bass method. Subjects were recalled after 14 days to evaluate
clinical parameters.
STATISTICAL ANALYSIS
ANOVA test was used for statistical anaysis. p value was
adjusted at < 0.05.
RESULTS
All the 30 subjects completed the study. The present study
was conducted to evaluate the effectiveness of indigenously
prepared 10% Camellia sinesis and 20% Punica granatum
mouthwash over 0.2% chlorhexidine mouthwash on Gingival
index, Plaque index and Calculus component of periodontal
index. All the clinical parameters were evaluated at baseline
and after 14 days.
After professional oral prophylaxis by a single periodontist,
subjects were allocated in the 3 group randomly.
Table 1 shows mean scores of all the three clinical parameters
at baseline and at 14 days.
On comparison of Group I and Group II, no significant
difference was seen (p = 0.510), suggesting 10% Camellia
sinesis and 20% Punica granatum mouthwashes have similar
effect on gingival index.
Table 1: Mean scores of clinical parameters
Clinical parameters
Group I Group II Group III
At
base-line
14 days
post-operative
At
base-line
14 days
post-operative
At
base-line
14 days
post-operative
Gingival index 1.65 0.46 1.50 0.65 1.67 1.03
Plaque index 1.47 0.36 1.50 0.67 1.49 0.89
Calculus component of
periodontal index 1.86 0.10 1.74 0.20 1.62 0.30
Champaneri et al. : Effectiveness of Indigenously Prepared Punica Granatum and Camellia Sinesis Mouthwashes as An Adjunct to Non Surgical Periodontal Therapy...
30 Journal of Nepalese Society of Periodontology and Oral Implantology : Vol. 1, No. 1, Jan-Jun, 2017
While comparing Group I and Group III, significant difference
was seen (p = 0.001), suggesting 10% Camellia sinesis has a
better effect than 0.2% Chlorhexidine mouthwash on gingival
index.
A significant difference (p = 0.027) was also found on
comparing gingival index scores of Group II an Group III,
suggesting 20% Punica granatum has better effect than
0.2% Chlorhexidine mouthwash.
Group I also showed significantly greater reduction in plaque
index score as compared to Group II (p = 0.026) and Group
III (p = 0.001).
Group II and Group III showed similar reduction in plaque
index score (p = 0.163). 10% Camellia sinesis showed better
results in plaque reduction as compared to 20% Punica
granatum and 0.2% Chlorhexidine mouthwash.
There was no statistically significant difference in the
Calculus component of periodontal disease index when inter-
group comparisons was made at the 14
th
day, suggesting all
mouthwashes had similar effect on calculus formation.
DISCUSSION
Though around 6000 plants in India are used in herbal
medicines, little research has been conducted on efficacy,
safety and properties of herbal products. Over the decades,
very few studies have been conducted to show the clinical
efficacy of Punica granatum and Camellia sinesis. In the
present study, it was demonstrated that hydroalcoholic
extract from Camellia sinesis leaves and Punica granatum rind
(peel) exerted a significant reduction in clinical parameters.
Analysis of plaque index values suggests that all three
mouthwashes were helpful in reducing plaque accumulation
over the 14 days study period, but Punica granatum
mouthwash reduced plaque scores to a greater extent as
compared to chlorhexidine. These findings are contrary to
the studies by Haffajee et al.
10
, Ahuja et al.
8
and Overholser
et al.
11
who showed that Chlorhexidine was better in reducing
plaque score than Punica granatum. The difference in the
results may be because of difference in the methodology
employed, i.e., instead of Punica granatum whole fruit,
only the peel of Punica granatum was taken for extract
preparation in our study. In a clinico-microbiological study,
Menezes et al.
12
showed that after 1 minute of rinsing,
greater reduction in plaque score was observed with Punica
granatum (84%) mouth wash as compared to Chlorhexidine
mouthwash (79%), which was in accordance to our results. In
our study, Camellia sinesis mouthwash reduced plaque score
to a greater extent as compared with Punica granatum and
chlorhexidine mouthwash. These findings are in agreement
with the studies by Jenabian et al.
6
and Moghbel et al.
13
Analysis of gingival index scores revealed that Punica
granatum was more efficient than chlorhexidine in reducing
gingival index score. Similar results were also reported by
Haffajee et al.
10
and Ahuja et al.
8
A study by Salgado et al
in 2006 on 10% Punica granatum gel does not support our
finding as this gel was not efficient in preventing supragingival
dental plaque formation and gingivitis.
14
Camellia sinesis
mouthwash reduced gingival score to a greater extent when
compared to Punica granatum and chlorhexidine mouthwash.
These findings are also in agreement with the studies by
Jenabian et al.
6
and Moghbel et al.
13
Analysis of calculus component of periodontal index showed
no statistical significance amongst all three groups.
In an urge of looking for better antiplaque and antigingivitis
agents with limited side effects as compared to chlorhexidine,
various herbal products have been tried with fruitful results.
Punica granatum and Camellia sinesis are recent herbal
product used in field of dentistry. So, more clinical and
microbiological studies on a long-term basis are required to
elicit the precise effectiveness of this product.
Table 2: Comparison of Gingival index scores at 14 days
Parameters Groups
(n=10) p value
Gingival index
Group I vs Group II 0.510
Group I vs Group III 0.001*
Group II vs Group III 0.027*
p<0.05; Significant
Table 3: Comparison of Plaque index scores at 14 days
Parameters Groups
(n=10) p value
Plaque index
Group I vs Group II 0.026*
Group I vs Group III 0.001*
Group II vs Group III 0.163*
p<0.05; Significant
Table 4: Comparison of Calculus component of
periodontal index scores at 14 days
Parameters Groups
(n=10) p value
Calculus component of
periodontal index
Group I vs Group II 1.000
Group I vs Group III 1.000
Group II vs Group III 1.000
p<0.05; Significant
Champaneri et al. : Effectiveness of Indigenously Prepared Punica Granatum and Camellia Sinesis Mouthwashes as An Adjunct to Non Surgical Periodontal Therapy...
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Journal of Nepalese Society of Periodontology and Oral Implantology : Vol. 1, No. 1, Jan-Jun, 2017
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5. Makimura M, Hirasawa M, Kobayashi K, et al: Inhibitory effect of tea catechins on collagenase activity. J Periodontol. 1993;64:630–6.
6. Jenabian N, Moghadamnia AA, Karami E, Pooorsattar BM. The effect of Camellia Sinensis (green tea) mouthwash on plaque-induced
gingivitis: a single-blinded randomized controlled clinical trial. DARU J Pharm Sci. 2012;20:39-46.
7. Menezes SM, Cordeiro LN, Viana GS. Punica granatum (pomegranate) extract is active against dental plaque. J Herb Pharmacother.
2006;6:79-92.
8. Ahuja S, Dodwad V, Kukreja BJ, Mehra P, Kukreja P. A comparative evaluation of efficacy of Punica granatum and chlorhexidine on
plaque and gingivitis. J Int Clin Res Organ. 2011;3:29-31.
9. Kukreja BJ, Dodwad B. Herbal mouthwash – A gift of nature. Int J Pharm & Bio Sci. 2012;3;2-9.
10. Haff ajee AD, Yaskell T, Socransky SS. Antimicrobial Eff ectiveness of an Herbal Mouthrinse Compared With an Essential Oil and a
Chlorhexidine Mouthrinse. J Am Dent Assoc. 2008;139:606-11.
11. Overholser CD, Meiller TF, DePaola LG, Minah GE, Niehaus C. Comparative effects of 2 chemotherapeutic mouthrinses on the
development of supragingival dental plaque and gingivitis. J Clin Periodontol. 1990;17:575-9.
12. Menezes SM, Cordeiro LN, Viana GS. Punica granatum (pomegranate) extract is active against dental plaque. J Herb Pharmacother.
2006;6:79-92.
13. Moghbel A, Farjzadeh A, Aghel N, Agheli H, Raisi N. The effect of green tea on prevention of mouth bacterial infection, halitosis, and
plaque formation on teeth. Irn J Toxicology. 2011;5:14-21.
14. Salgado AD, Maia JL, Pereira SL, de Lemos TL, Mota OM. Antiplaque and antigingivitis eff ects of a gel containing Punica granatum Linn
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CONCLUSION:
In the absence of vigilant oral care, plaque and calculus will
build up resulting in gingivitis and possibly progressing to
periodontitis. So, various herbal products have been tried
and have shown promising results with minimal side effects.
Also, their additional effect on inflammatory pathways
and antioxidant potential make them eligible to be used
as effective antigingivitis agents. Our study concluded
that Camellia Sinesis mouthwash and Punica Granatum
mouthwash are better antigingivitis and antiplaque agent
than chlorhexidine mouthwash.
Champaneri et al. : Effectiveness of Indigenously Prepared Punica Granatum and Camellia Sinesis Mouthwashes as An Adjunct to Non Surgical Periodontal Therapy...
