The Difference Between Gargling Using Betel Nut Seed (Areca Catechu) Extract and Chlorhexidine 0.2% Solution in Chronic Gingivitis Healing

Abstract

The use of mouthwash is an effective way to help cure gingivitis. Mouthwash that is often used is mouthwash containing antiseptic. Recently, there has been increasing use of traditional medicines that are considered safer such as areca nuts compared to chemically synthesized agents. The aim of this study was to calculate the difference in the healing of chronic gingivitis due to calculus between gargling using areca nut (Areca catechu) extract and using Chlorhexidine 0.2% solution. This was an experimental test with pre and post-test control group design and involved two treatment groups. A total of 30 subjects with grade 2 gingivitis were being admitted. The first group was given mouthwash with areca nut (Areca catechu) extract and another group with Chlorhexidine 0.2% twice daily for three days. The mean gingival index in the group which gargled using betel nut seed (Areca catechu) extract on the first day was 1,93±0,704 followed by 0,40±0,507 on the second day, and 0,00±0,00 on the third day, on the other hand the mean gingival index in the group which gargled using Chlorhexidine 0.2% solution was 1,93±0,704 on the first day, 0,40±0,507 on the second day, and 0,00±0,00 on the third day. The mean gingival index decreased significantly during observation period in both treatment groups but when being compared to each other there was no significant difference in the healing time of chronic gingivitis in group which gargled using betel nut seed extract (Areca catechu) and Chlorhexidine 0.2% solution.

Full text

Biomedical & Pharmacology Journal, June 2019. Vol. 12(2), p. 723-727
Published by Oriental Scientific Publishing Company © 2019
This is an Open Access article licensed under a Creative Commons license: Attribution 4.0 International (CC-BY).
The Difference Between Gargling Using Betel Nut Seed
(Areca Catechu) Extract and Chlorhexidine 0.2%
Solution in Chronic Gingivitis Healing
I Gusti Agung Ayu Putu Swastini1, I Gusti Agung Ayu Dharmawati1,
Ni Nengah Sumerti2, Tjokorda Gde Bagus Mahadewa3*
and I Putu Eka Widyadharma4
1Health Polytechnic Denpasar, Bali, Indonesia.
2Department of Dental Nursing, Health Polytechnic Denpasar, Bali, Indonesia.
3Department of Neurosurgery, Faculty of Medicine,Udayana University,
Sanglah General Hospital, Bali, Indonesia.
4Department of Neurology, Faculty of Medicine, Udayana University,
Sanglah General Hospital, Bali, Indonesia.
*Corresponding author E-mail: tjokmahadewa@unud.ac.id
http://dx.doi.org/10.13005/bpj/1694
(Received: 16 March 2019; accepted: 16 May 2019)
The use of mouthwash is an effective way to help cure gingivitis. Mouthwash that
is often used is mouthwash containing antiseptic. Recently, there has been increasing use of
traditional medicines that are considered safer such as areca nuts compared to chemically
synthesized agents. The aim of this study was to calculate the difference in the healing of chronic
gingivitis due to calculus between gargling using areca nut (Areca catechu) extract and using
Chlorhexidine 0.2% solution.This was an experimental test with pre and post-test control group
design and involved two treatment groups. A total of 30 subjects with grade 2 gingivitis were
being admitted.The first group was given mouthwash with areca nut (Areca catechu) extract
and another group with Chlorhexidine 0.2% twice daily for three days.The mean gingival
index in the group which gargled using betel nut seed (Areca catechu) extract on the first day
was 1.93±0.704 followed by 0.40±0.507 on the second day, and 0.00±0.00 on the third day, on
the other hand the mean gingival index in the group which gargled using Chlorhexidine 0.2%
solution was 1.93±0.704 on the first day, 0.40±0.507 on the second day, and 0.00±0.00 on the
third day.The mean gingival index decreased significantly during observation period in both
treatment groups but when being compared to each otherthere was no significant difference
in the healing time of chronic gingivitis in group which gargled using betel nut seed extract
(Areca catechu) and Chlorhexidine 0.2% solution.
Keywords: Gingivitis; betel nut seed extract; Chlorhexidine; gargling.
Chronic marginal gingivitis is one type
of inammation in the gingiva which includes the
gingival margin and can include the part adjacent
to the attached gingiva. One way to measure the
level of inammation in the gingiva is by assessing
the bleeding that occurred during the probing1.
Gargling is one method of cleaning teeth and
mouth. This is mostly be done after brushing teeth.
Mouthwash is not only considered as a breath
freshener solution that has an aroma or no effect
on the health of the oral cavity but mouthwash can
also reduce plaque in gingivitis2.

724 SwaStini et al., Biomed. & Pharmacol. J, Vol. 12(2), 723-727 (2019)
Many types of mouthwashes that contain
antimicrobial ingredients may help control the
growth of supragingival plaque and gingivitis,
but there are several chemicals on mouthwashes
that can cause side effects such as cancer because
they contain alcohol3. Alternatives to the use of
natural ingredients as a substitute for chemical
mouthwash are still the people’s choice because
they are cheaper and have fewer side effects
compared to synthetic ingredients4. The use of
traditional herbal medicines has often been used
for the treatment of other infectious diseases. The
World Health Organization (WHO) has given
policies to developing countries to use traditional
herbal medicines as the rst treatment or treatment
when sick. Indonesia is the second richest country
in the world after Brazil for biodiversity. The use
of medicinal plants is an alternative for treatment
approach in this area, with betel nut (Areca
catechu) as one example5.
Betel nut has been widely used by the
people of Indonesia, since long ago it has been
used as a mixture of betel nut. People believed
that eating betel nuts can strengthen their teeth,
even though they are already old. The betel nut
contains antimicrobial substances that interfere
with the metabolism of microorganisms. The
most abundant and effective substances used in
mouthwash products are Chlorhexidine which
contains Chlorhexidinedigluconate. The way these
mouthwash works is by changing the composition
of oral bacteria, this effect is considered meaningful
but it only lasts when the product is being used
6. The results of the study done by Sugianitriin
2011 showed that areca seed extract can inhibit
the growth of microorganisms (Candida albicans
colonies), which was carried out in soaking denture
stomatitis7.
Based on the background described, the
researcher wanted to know the difference in the
healing of chronic gingivitis because of calculus
between gargling using areca seed extract and
Chlorhexidine 0.2%.
MATERIAL AND METHODS
Material
The areca seeds (Areca catechu L.) was
collected from young fruits. The areca nut was
peeled, then the seeds were air-dried under the sun.
The dried seeds were mashed using a dry blender
into powder form. A total of 250 grams of dry
powder was put into the macerator, a 96% ethanol
as much as 7 ½ times the weight of the powder
was added and the mixture was stirred evenly. The
concoction was left for 5 days in a closed macerator
with constant stirring every day. A Buchner funnel
was used to strain the solution, then left precipitated
for 2 days, carefully separating the liquid from the
precipitate. At the nal stage, the macerate was
evaporated in a porcelain dish on top of a water
bath or by rotary evaporator at a temperature of
45-50o C with low pressure (± 15 mmHg) to obtain
a thick, brownish yellow extract8.
Methods
Research subjects selection
This research was conducted in June-
October 2015, at the Department of Nursing
Dental Clinic, Health Polytechnic of Denpasar.
The examination was conducted on Ganesha
Junior High School students in Denpasar to obtain
students with a diagnosis of Grade 2 gingivitis.
Subjects who met the inclusion criteria were
randomized into two equal groups with 15 subjects
in the treatment group (mouth rinsing with betel nut
seed extract) and 15 subjects mouth rinsing with
Chlorhexidine 0,2% solution.
Preparation for Gargling
Gargling was done two to three times a
day according to the package instruction of the
Chlorhexidine 0.2% solution. Each rinse used
10 mL solution and should be performed for 30
seconds. After expelling the solution, let stand for
15-30 minutes.This procedure was done at each
subjects’ residences, monitored by the respective
parents or friends appointed by the researchers.
The entire procedure wasthen recorded. On the
following day, the subjects visited the JKG Clinic
to perform back the mouth rinsing (done after teeth
brushing). The gingival index was assessed then
photographed to compare changes in the gingiva9.
The aforementioned steps were performed
repeatedly until the gingival index reached 0, which
showed signs of occurring healing. Data normality
test was conducted using the Shapiro-Wilk test with
signicance level α = 0.05. The non parametric
Friedman test was done to analyze the differences
in the decrease of gingival index between the
treatment and control groups.

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SwaStini et al., Biomed. & Pharmacol. J, Vol. 12(2), 723-727 (2019)
Table 1. Characteristics of the studied patients
Junior High Gender Students
School Grade Male Female Number
7th grade 5 5 10
8th grade 5 5 10
9th grade 5 5 10
Total 15 15 30
Table 2. The mean gingival index before and aftergargled usingbetel nut seed extract
Variable Betel Nut Seed Extract χ2 P
Day 1 Day 2 Day 3
Gingival Index 1.93±0.704 0.40±0.507 0.00±0.00 18.17 0.000
Table 3. The mean gingival index before and after gargledusingChlorhexidine 0.2% solution
Variable Chlorhexidine 0,2% Solution χ2 P
Day 1 Day 2 Day 3
Gingival Index 1.20±0.561 0.20±0.414 0.00±0.00 25.41 0.000
RESULTS
A total of 30 subjects were enrolled in this
study. The characteristics of eligible subjects are
presented in Table 1.
In the present study the number of students
who meet the requirements to be included on this
study was 30 people, consisting of 15 men and 15
women. The mean gingival index of the studied
patients before and after mouth washing with betel
nut seed extract decreased signicantly during
observation (p <0.05) as presented in Table 2.
Table 3 displayed the gingival index
decreased signicantly during observation period
in the group that rinse with Chlorhexidine 0.2%
solution.
Table 4 shows that the mean gingival
index in the two different treatment groups on day
one of study did not differ signicantly (p> 0.05).
There was no signicant difference in the mean
gingival index between the two treatment groups
in the second (p>0.05) and third day (p>0.05) of
the study as depicted consecutively in Table 4 and
Table 5.
There was complete recovery on all of the
study subjects on the third day as shown in Table
7. Statistical analysis using Wilcoxon test showed
that the meanhealing time on both groups did not
differ signicantly (p> 0.05), the result is displayed
in Table 8.
DISCUSSION
The results of this study showed
a significant decrease in the gingival index
after mouth rinsing with betel nut extract and
Chlorhexidine 0.2% solution. Gargling will produce
a mechanical and chemical cleansing effect.
Mechanical effects are obtained from dynamic
movements of gargling, while the chemical
effects results from the active ingredients of the
mouthwashcontainingantibacterial agents. The
decrease of gingival index after gargled using areca
fruit extract was likely to occur since betel nuts
contain several substances including polyphenols,
tannins, fats, sugar, water, and oil which contains
alkaloids, avans, phenolic compounds, gallic
acid, sap, lignin, and salt10. The catechins and
polyphenols possess bothbacteriostatic and
bactericidal functions againstStreptococcus
mutansbacteria11.
Catechins work by inhibiting the adhesion
of Streptococcusmutans so that the activity of the
glucosyltransferase enzyme is inhibited and the
acid product is not formed. Catechins damage
bacterial cell walls and cytoplasmic membranes
and cause protein denaturation12.
The biological activities of avonoids on
bacteria damage bacterial cells, which consist of
lipids and amino acids react with alcohol groups in
avonoids so that the cell wall will be damaged and
these compounds enter the nuclei of bacterial cells
and contact with DNA in the nuclei of bacterial

726 SwaStini et al., Biomed. & Pharmacol. J, Vol. 12(2), 723-727 (2019)
Table 5. The mean gingival index between the two treatment groups on Day Two
Treatment Group Number Mean SD Z P-value
Gingival Index
Betel nut seed extract 15 0.40 0.507 -1.18 0.24
Chlorhexidine 0.2% solution 15 0.20 0.414
Table 6. The mean gingival index between the two treatment groups on Day Three
Treatment Group Number Mean SD Z P-value
Gingival Index
Betel nut seed extract 15 0.00 0.00 0.00 1.00
Chlorhexidine 0.2% solution 15 0.00 0.00
Table 7. The frequency of subjects with complete
healing on the third day of the study
Treatment groups Number Frequency
of complete
healing
Betel nut seed extract 15 100%
Chlorhexidine 0.2% solution 15 100%
Table 8. The mean gingival healing time between the two treatment groups
Treatment groups Number Mean SD Z P-value
Healing
Time
Betel nut seed extract 15 2.35 0.45 -1.38 0.902
Chlorhexidine 0.2% solution 15 2.29 0.66
cells. The difference in polarity between lipid
compilers of DNA and alcohol groups in avonoid
compounds damages the structure of lipid DNA and
cell nucleus13.
In the Chlorhexidine group the decline
in the gingival index were statistically signicant
(p <0.05), this is may be caused by the ability of
Chlorhexidine to bind bacteria, interactions between
the positively charged Chlorhexidine molecules
with negatively charged bacterial cell walls. This
interaction will increase the permeability of the
cell wall of the bacteria that cause penetration into
the cytoplasm causes the death of microorganisms.
Certain streptococci can be bound by Chlorhexidine
in polysaccharides media, thus increasing the
sensitivity of streptococci in the oral cavity against
gingivitis cure Chlorhexidine. In both treatment
groups, the healing process after the third day of
treatment were equal (15 subjects in each group,
100%). Further statistical analysis showed that the
average healing time using the gingival index after
the third day in both groups was not signicant
(p> 0.05).
While Chlorhexidine is a cationic
biguanide, with a very broad antimicrobial
activity,its antimicrobial effects are associated
with the interaction between Chlorhexidine 0,2%
and bacterial cells that are negatively charged.
After Chlorhexidineis absorbed in the surface of
the bacterial cell wall, Chlorhexidine will reduce
the resilience of the cell membrane and cause the
release of intracellular materials. There was a
study showing that using Chlorhexidine 0.2% as
a mouthwash for a week could reduce the plaque
index as much as 72% on the third day, and
85% on the seventh day.This resulted from the
binding of Chlorhexidine with the tooth surface
molecules such as polysaccharides, proteins,
glycoproteins, saliva, mucous pellicles, as well as
the hydroxyapatite surface, inhibiting the plaque
formation as the main cause of gingivitis6.

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SwaStini et al., Biomed. & Pharmacol. J, Vol. 12(2), 723-727 (2019)
CONCLUSION
Based on the result from the research it
can be concluded that mouthrinsing with either
betel nut seed extract and Chlorhexidine 0.2%
solution has the ability on the healing of second
grade chronic gingivitis. The mean healing time
between both groupswas not signicantly different.
ACKNOWLEDGMENTS
The authors received no external funding
in conducting this study.
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