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Comparison of effectiveness of Salvadora persica with commercial whitening toothpastes (Erlina Sih Mahanani et al.)
Correspondence author: Erlina Sih Mahanani, School of Dental Sciences, Universiti Sains Malaysia, 16150 Kubang Kerian,
Kelantan, Malaysia
Comparison of effectiveness of Salvadora persica whitening
toothpaste with commercial whitening toothpaste at
removing stain
Erlina Sih Mahanani, Erry Mochamad Arief, Samantha Victoria Samuel
School of Dental Sciences, University Sains Malaysia
ABSTRACT
The miswak, a traditional chewing stick for cleaning teeth, is made from the plant Salvadora
persica. It contains wide range of healthy components in maintaining good oral hygiene. The objective of
this study is to determine the effectiveness of whitening toothpaste containing Salvadora persica extract
at removing tea and chlorhexidine stain by comparing with one of commercially available whitening
toothpaste and drinking water as control group. A randomized experimental study was done. The standard
method cycled clear acrylic specimens through articial saliva, 0.2% chlorhexidine and tea on the hour
8 times per day and stain was measured using a spectrophotometer to achieve baseline reading. Test
interventions were 2 whitening toothpastes; whitening toothpaste containing Salvadora persica extract
(group A), commercial whitening toothpaste (group B) and drinking water as control group (group C).
Treatment interventions were done at 09:00 and 16:00 by exposing the specimens to slurries of each
treatment for 2 minutes. The specimens remained in the articial saliva between each cycles day and
night. At the end of the day, the stain was assessed by spectrophotometer and Lobene Stain Index. The
comparison of total stain removal assessed by spectrophotometer on day 5 between all groups was
signicant (p=0.007). The median of total stain removal and visual assessment recording using Lobene
stain index showed Salvadora persica whitening toothpaste scored more reduction of staining followed
by commercial whitening toothpaste and then control group. As conclusion, the whitening toothpaste
containing Salvadora persica is more effective at removing tea and chlorhexidine stain.
Key words: Salvadora persica, whitening toothpaste, staining
INTRODUCTION
Dental staining can occur on the external
surface of the tooth (extrinsic staining) or within
the tooth substance (intrinsic staining). The
extrinsic stain may be removed by tooth brushing,
scaling or prophylaxis but the intrinsic stain cannot
be removed.
Clinical and in vitro studies have implicated
dietary components as major aetiological factors
in staining of teeth and acrylic materials associated
with chlorhexidine.1 The combination of tea and
chlorhexidine appears to be a very potent staining
factor for extrinsic stain.2 The interaction of
chlorhexidine with dietary chromogens to cause
extrinsic dental staining has been exploited in
vitro and in vivo to study tooth discoloration
and its control.3 Study by Leard and Addy4 has
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Padjadjaran Journal of Dentistry 2009;21(3):155-159.
indicated that tea and coffee contribute to dental
and tongue staining associated with chlorhexidine
mouthrinses.
Mouthwash containing chlorhexidine causes
supercial black and brown staining of the teeth.5,6
The staining is enhanced in the presence of tea
and coffee. It may be related to the precipitation
of chromogenic dietary factors to the teeth and
mucous membranes.5 It is probable that the
associated cationic group attaches chlorhexidine
to the tooth, while the other cationic group
producing the bacteriocidal effect can attach the
dietary factors, such as gallic acid derivatives
(polyphenols) found in foods and beverages such
as tea and coffee and tannins, from wine to the
molecule and hence to the tooth surface.4,6 It was
found that chlorhexidine absorbed to the pellicle
and caused a modication of the pellicle properties,
leading to subsequent increase in adsorption of
salivary and black tea components. This increase
in adsorption resulted in a concomitant increase
in the stain.7
The miswak, a traditional chewing stick for
cleaning teeth, is made from the plant Salvadora
persica.8 The popularity and availability of this
chewing stick in the Asia, Middle East, and Africa
make them a commonly used oral hygiene tool
in those societies.9 It has been shown to containIt has been shown to contain
trimethylamine, salvadorine, chloride, uoride,
silica, sulphur, mustard oil, vitamin C, resins and
traces of tannins, saponins, avonids and sterol.10,11
Hatabtab12 analyzed the sticks from Salvadora persica
for their soluble and total content of ouride,
calcium, phosphorus and silica. There was a
substantial amount of silica in the ashes of miswak.
It appears that miswak is probably not particularly
active against caries through its uoride content,
but it does act as a brush for removing dental
plaque and polishing the teeth.
As the dental aesthetics are highly
concerned nowadays, there has been increase
in the demand from consumers and patients for
products that whiten teeth. A number of whitening
toothpastes have been formulated to inhibit or
remove extrinsic staining of teeth.13 Some of the
manufacturers had produced whitening toothpaste
containing Salvadora persica extract. Salvadora
persica is a common source to be used as miswak
(chewing stick). For religious and cultural reasons,
miswak use is rmly established and widespread
in most of Muslim countries. It has been shown
to contain trimethylamine, salvadorine, chloride,
uoride, silica, sulphur, mustard oil, vitamin C,
resins and traces of tannins, saponins, avonids
and sterol.11,14 Many studies have demonstrated
the antiplaque, antiperiopathic, anticaries and
antibacterial effect of it. However, there is
no study reported yet regarding its efcacy at
removing tea and chlorhexidine stain in comparing
with any commercially available whitening
toothpaste. Therefore, this study was conducted
to determine the effectiveness of whitening
toothpaste containing Salvadora persica compared
to one of commercial whitening toothpaste and
drinking water as control group at removing tea
and chlorhexidine stain.
MATERIALS AND METHODS
Sixty acrylic blocks measuring 4.5x1x1cm
were cut and polished to t the specimen
chamber of a UV/visible spectrophotometer.
Firstly, all specimens were stained until reached
the baseline optical reading of spectrophotometer
(1.500–1.700). Then the specimens were randomly
divided into 3 groups according to the respective
treatment regimen.
The staining was produced by cycling
specimens through articial saliva for 2 minutes,
a 0.2% chlorhexidine mouth rinse for 2 minutes
and a tea solution for 30 minutes. The tea solution
was produced by mixing 5 teabags of tea in 1
litre of water at 50°C temperature. The whole
staining process was repeated for 8 times a day.
The specimens were rinsed with distilled water
after each component of cycle was done. Baseline
optical density readings for range between 1.500-
1.700 were taken for all specimens by using
spectrophotometer at lambda maximum of 700
nm. The staining of specimens were also graded
visually using the intensity score of the Lobene
stain index (0=no stain, 1=light stain, 2=moderate
stain, 3=heavy stain).15
For both toothpastes, standard slurry was
prepared by thoroughly mixing 5 gm toothpaste
in 200 mL distilled water using rotary mixer. This
preparation was done to exclude any activity
because of presence of abrasives in either
toothpaste when applied to toothbrush. The
specimens were exposed to the slurries for 2
157
Comparison of effectiveness of Salvadora persica with commercial whitening toothpastes (Erlina Sih Mahanani et al.)
minutes. The treatment regimens were whitening
toothpaste containing Salvadora persica (Sa
kayu sugi whitening toothpaste) as Group A.
Gommercially available whitening toothpaste
we used Colgate Herbal White (Group B) and
drinking water as control group (Group C). The
interventions of whitening were done at 09:00
am and 16:00 pm. After the second intervention,
the specimens were rinsed briey with distilled
water, bench dried and the optical density read
on the spectrophotometer and visual assessment
recording using Lobene stain index.15 The optical
density reading was done for 3 times on the same
surface of each specimen. The visual assessment
was done by one investigator. All specimens were
left in the articial saliva until the next cycle
in the next day. The experiment was done for 5
days.
RESULTS
The difference of median total stain
removal from spectrophotometer reading among
groups after 5 days of interventions was signicant
(p=0.007) is shown in Table 1. Salvadora persica
(group A) shows the highest median (IQR), followed
by commercial whitening toothpaste (group B) and
control group is the lowest.
The visual assessment recording using
Lobene stain index for all groups before the
treatment interventions scored grade 3 (heavy
stain). On day 5, the result from Table 2 and Figure
1 shows that group C has the highest percentage-
scoring grade 3 while group B was less and none
of group A scored grade 3. It means that group
A (Salvadora persica whitening toothpaste) has
highest ability to remove the stain.
DISCUSSION
This model of stain formation or stain
removal has been used for many years in dental
research. Optically clear acrylic has been used
since it is a common dental material which appears
to stain in a similar manner to enamel. Besides, it
also has the advantage of allowing accurate optical
density readings to be obtained.14 Using the same
brand of tea and chlorhexidine standardize the
staining effect on the specimens. The specimens
Visual Assessment Using Lobene
(1968) Stain Index On Day 5
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
group A group B group C
grade 1
grade 2
grade 3
Figure 1. Percentage of specimens in each groups scored
for each grade on day 5.
Variable Group n Median (IQR) Z Statistics (df)aP valuea
Total stain removal A 20 0.2795(0.45)
B20 0.2525(0.24) 9.935 0.007
C20 0.1340(0.15) (2)
Table 1. Comparing numerical variables between 3 groups on day 5
aKruskall-Wallis test
Table 1. Frequency distribution of grades using Lobene stain index on day 5
Note: 0=No stain, 1=light stain, 2= moderate stain, 3 heavy stain
Group
Grade
Total
n (%)
3
n (%)
2
n (%)
1
n (%)
0
n (%)
A17(85) 3(15) 20(100)
B2(10) 15(75) 3(15) 20(100)
C11(55) 9(45) 20(100)
Total 13(21.7) 41(68.3) 6(10) 60(100)
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Padjadjaran Journal of Dentistry 2009;21(3):155-159.
were treated with saliva to form an initial pellicle
layer and facilitate the uptake of the stain.16 The
articial saliva was used as replacement for human
saliva to create standard saliva used throughout
this study. To get the human saliva from the same
person was time consuming and it was afraid that
any changes of the saliva properties during period
the study may affect the results of study. The
articial saliva that has been used was produced by
Pharmacological Laboratory of HUSM. It contains
syrup, lemon, spirit and glycerol with pH 6.5.
In this study, the specimens were stained
with tea solution at 50°C. Tea temperature was
signicantly inuenced staining and the maximum
staining effect of tea was at 50°C. Chlorhexidine
temperature did not inuence staining.
Spectrophotometer reading was highly sensitive
since it can detect the difference of stain removal
in within 5 day. Therefore, the study could be
done in 5 days. The interventions were done twice
a day at 09:00 and 16:00 to t more closely with
morning and evening tooth brushing.3
Whitening toothpaste with Salvadora
persica extract (Sa Kayu sugi whitening
toothpaste) contains calcium carbonate,
water, sorbitol, glycerine, silica, sodium
lauryl sulphate, cellulose gum, avour, sodium
benzoate, sodium saccharin, Salvadora persica
and sodium monouorophosphate. The Colgate
Herbal Whitening toothpaste (group B) contains
calcium carbonate, water, sorbitol, hydrated
silica, sodium lauryl sulphate, avour, sodium
monouorophospahate, sodium carbonate,
cellulose gum, sodium saccharin, carrageenan,
xanthan gum, methylparaben, propylparaben,
Melissa ofcinalis extract, Lonicera caprifolium
extract, Citrus medica limonium oil and pearl
powder. Abrasive agents in toothpaste are believed
to remove stain on teeth. The abrasive agents in
both toothpastes that were used in this study were
calcium carbonate and silica. Another abrasive
agent in the commercial whitening toothpaste was
sodium carbonate, pearl powder. However, the
abrasives effects were excluded in this study as the
specimens were placed in the toothpaste slurries
during the treatment interventions. Therefore,
the whitening effect of these toothpastes was
most probably due to the chemical effect.
The combination of herbal extracts (Melissa
ofcinalis and Lonicera caprifolium, Citrus me-
dica limonium oil) and abrasive agents in the
commercial whitening toothpaste are claimed
by the manufacturer to be involved in staining
removal. Addition of Salvadora persica in the
whitening toothpaste gives signicant effect
at removing tea and chlorhexidine stain. The
results of this study showed that the whitening
toothpaste containing Salvadora persica is more
effective at removing tea and chlorhexidine stain
compared to the commercially available whitening
toothpaste. According to Darout17, release of
benecial substances in Salvadora persica have
been suggested to contribute to the cleaning
efcacy of miswak. High concentration of chloride
in Salvadora persica was suggested inuencing the
result as it was reported to help in removing stains
from teeth.9 Further research may be required to
study regarding the chemical agents in Salvadora
persica that probably cause stains removal.
From the study, drinking water that has been
used as control group also showed some removal
of tea and chlorhexidine stain but it was minimal.
Therefore, rinsing with water may remove tea and
chlorhexidine stain to some minimal extension.
CONCLUSION
The whitening toothpaste containing
Salvadora persica is more effective at removing
tea and chlorhexidine stain compared to one of
commercially available whitening toothpaste.
The ability of this toothpaste due to the chemical
effect cause the intervention is remained in the
toothpaste slurries without brushing the surface
of specimens. Further study need to investigate
the mechanical effectiveness of this toothpaste.
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