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Research article
The effect of oil pulling with coconut oil to improve dental hygiene and oral
health: A systematic review
Julian Woolley
a
,
*
, Tatjana Gibbons
b
, Kajal Patel
a
, Roberto Sacco
c
a
King's College Hospital, King's College NHS Foundation Trust, UK
b
John Radcliffe Hospital, Oxford University Hospital Trust, UK
c
University of Manchester Division of Dentistry Manchester, UK
ARTICLE INFO
Keywords:
Dental surgery
Dentistry
Periodontics
Oral medicine
Alternative medicine
Coconut oil
Oil pulling
Ayurvedic medicine
Oral health
Dental hygiene
ABSTRACT
Objectives: Coconut oil is a cheap and accessible oil for many people around the world. There are numerous
advocates for the practice of oil pulling to prevent common oral diseases. Therefore determining the effectiveness
of oil pulling with coconut oil could potentially have monumental benefits. This review aimed to assess the effect
of oil pulling with coconut oil in improving oral health and dental hygiene.
Data: We included randomized controlled trials comparing the effect of oil pulling with coconut oil on improving
oral health and dental hygiene.
No meta-analysis was performed due to the clinical heterogeneity and differences in the reporting of data among
the included studies.
Sources: Six electronic databases were screened: PubMed, Medline, EMBASE, AMED, CENTRAL and CINAHL.
Study selection: Electronic searches yielded 42 eligible studies, of which four RCTs including 182 participants were
included. The studies lasted between 7 and 14 days. Significant differences were demonstrated for a reduction in
salivary bacterial colony count (p¼0.03) and plaque index score (p¼<0.001). One study also demonstrated a
significant difference in staining compared to using Chlorhexidine (p¼0.0002). However, data was insufficient
for conclusive findings, the quality of studies was mixed and risk of bias was high.
Conclusion: The limited evidence suggests that oil pulling with coconut oil may have a beneficial effect on
improving oral health and dental hygiene. Future clinical trials are of merit considering the universal availability
of the intervention. Prospective research should have a robust design with rigorous execution to provide a higher
quality of evidence.
Clinical significance: Oil pulling with coconut oil could be used as a adjunct to normal preventative regimes to
improve oral health and dental hygiene although further studies are needed to determine the level of
effectiveness.
1. Introduction
Oral hygiene habits are developed and established in early childhood
and aid in the prevention of dental caries and periodontal disease in the
future. Mechanical methods of tooth brushing are the most reliable and
widely accepted, however mouthwashes have also been used for a
number of years as an adjunctive measure for the maintenance of dental
hygiene and oral health [1].
Oil pulling is a traditional ayurvedic remedy originally practised in
ancient India for the maintenance of oral health. It is thought to cure over
thirty systemic diseases as well as conferring multiple oral health benefits
such as improvement in gingival health with reduced inflammation and
bleeding, resolution of symptoms of dry mouth/throat and chapped lips,
whiter teeth, reduced halitosis, improved oral hygiene and strengthening
of muscles and jaws in the oral cavity [2]. The procedure of oil pulling
involves swishing a measured volume of oil around the mouth for a
period of time, forcing the oil in between all the teeth and around the
mouth [2]. Examples of organic oils that are used include sunflower oil,
sesame oil, and coconut oil [2].
Coconut oil is composed mostly of medium chain fatty acids; it is
therefore unique compared to the majority of other dietary oils, which
are predominantly made up of long chain fatty acids. Approximately 50%
of these medium-chain fatty acids are lauric acid, known for its antimi-
crobial and anti-inflammatory benefits [3]. Previous in-vitro studies
* Corresponding author.
E-mail address: julianwoolley@gmail.com (J. Woolley).
Contents lists available at ScienceDirect
Heliyon
journal homepage: www.cell.com/heliyon
https://doi.org/10.1016/j.heliyon.2020.e04789
Received 14 July 2020; Accepted 21 August 2020
2405-8440/Crown Copyright ©2020 Published by Elsevier Ltd. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
Heliyon 6 (2020) e04789
using biofilm models have demonstrated the antimicrobial properties of
coconut oil against Streptococcus mutans and Candida albicans [4].
As coconut oil is a readily accessible and cheap material for most,
research into the effectiveness and efficacy of its use in the oil pulling
procedure is of clinical merit. As there have been no previous systematic
reviews undertaken specifically for coconut oil use in oil pulling, the aim
of this systematic review is to assess the available evidence and effec-
tiveness of this ayurvedic remedy in improving the oral health and dental
hygiene. This review has potential to offer another dimension in the role
of alternative medicine within dentistry.
2. Materials and methods
This systematic review was conducted according to Preferred
Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)
guidelines [5]. The protocol of this review was registered in the Inter-
national Platform of Registered Systematic Review and Meta-analysis
Protocols (INPLASY) under number INPLASY202060084.
2.1. Review question and PICO strategy
Is there sufficient evidence that coconut oil when used in an oil
pulling technique improves oral health and dental hygiene?
Population (P): any human participant
Intervention (I): oil pulling with coconut oil
Comparison (C): conventional oral hygiene routines and alternative
evidence-based interventions
Outcome (O): effect on oral health and dental hygiene
2.2. Information sources and search strategy
The following six databases were screened: PubMed, Medline,
EMBASE, AMED, CENTRAL and CINAHL (Figure 1). A comprehensive
search strategy for all six databases was developed focussing on Ayur-
vedic medicine in conjunction with oral health: Periodontal OR Perio-
dont OR Periodontitis OR Gingivitis OR Gingival OR Periodontal disease
OR Periodontics OR Oral OR Dental OR Oral health OR Oral hygiene OR
Dental hygiene OR Halitosis AND Coconut pulling OR Coconut oil OR Oil
pulling OR Ayurveda OR Ayurvedic medicine. The search strategy
included appropriate changes in the keywords and followed syntax rules
for each of the six databases.
A comprehensive screening method was employed to ensure preci-
sion within the search. One of the authors (JW) identified and removed
duplicates. The screening of titles and abstracts were carried out inde-
pendently by two authors (JW and TG) to eliminate any irrelevant ma-
terial. Disagreements were resolved by discussion until a consensus was
reached. If conflicts were not resolved, the studies were sent forward to a
third reviewer for resolution (KP). Finally two authors (JW and TG)
conducted full-text screening and completed data extraction using a
predefined and standardised Microsoft Excel form to:
- Verify the study eligibility derived from the inclusion/exclusion
criteria.
- Extract data on study characteristics and outcomes for the included
studies.
- Carry out a methodological quality assessment and risk-of bias
assessment.
Figure 1. Search strategy used to collect articles for systematic review.
J. Woolley et al. Heliyon 6 (2020) e04789
2
The authors of any studies eligible for inclusion in the review with
insufficient information were contacted directly using e-mail. Where
pooling of analogous data was inappropriate, the results of the trials were
reported as a narrative description using detailed commentary on the
study findings, interventions and controls and outcomes. No meta-
analysis was performed due to the clinical heterogeneity and differ-
ences in the reporting of data among the included studies.
2.3. Criteria for inclusion
Studies included in the research strategy, included published or un-
published randomised controlled trials. The last updated search was
performed in June 2020. No restrictions were imposed regarding year/
time of publication to maximise the pool of appropriate studies. No re-
striction of age, gender, sample size or ethnic origin was applied. There
were no language restrictions enforced on the search.
Animal studies, in vitro studies, studies without a randomised-
controlled design, reviews and studies not using coconut oil as an
intervention were excluded.
2.4. Objectives
The objective of this review was to appraise all data from randomised
controlled trials to determine whether there is sufficient evidence that
coconut oil when used in an oil pulling technique improves dental hy-
giene and oral health compared to other conventional and evidence-
based interventions.
2.5. Outcomes measured
The primary outcome was to determine whether oil pulling with co-
conut oil improves oral health.
The secondary outcomes were to determine whether the duration of
use and method of delivery of coconut oil affect oral health and dental
hygiene. In addition, the review sought to compare this to alternative
conventional interventions.
2.6. Data extracted
All selected papers were carefully read to identify author(s), year of
publication, study design, population sample, interventions and oral
hygiene adjustments. To assess our primary outcome, all data corre-
sponding to oral health measures were extracted from the studies
including plaque index (PI), gingival index (GI), stain index (SI), bleeding
on probing (BOP), salivary Streptococcus Mutans (SM) count and salivary
bacterial colony (BC) count.
2.7. Risk of bias and review of quality assessment
Two authors (JW and TG) independently appraised the risk of bias in
this review. The Cochrane Handbook for Systematic Reviews of In-
terventions was used to appraise the risk for each randomised controlled
trial (Figures 2and 3)[6]. In addition, the quality of included studies was
assessed according to the levels of evidence for therapeutic studies from
the Centre for Evidence-Based Medicine, Oxford [7](Table 1). Dis-
agreements were resolved through discussion.
3. Results
3.1. List of excluded studies
Figure 1 shows the search strategy that was employed to gather
relevant publications for this review. Following the initial search, we
considered thirty-eight studies to be potentially eligible for inclusion, but
after comprehensive screening of the full articles, thirty-four were
excluded for not meeting the inclusion criteria for this review (Table 2).
The four papers were then subsequently analysed for data extraction.
3.2. Analysis of measured outcomes
A total of four randomised-controlled studies were included in this
systematic review [8,9,10,11] (Tables 3and 4). All the published data
described patients treated between 2015 and 2019. The total number of
subjects involved in these four studies was 182. The age range of the
participants was between 6 and 52 years. Only three studies reported a
mean age [8,9,10]. The mean for this review was 22.3 years.
All four studies used coconut oil as an intervention for oil pulling
(OIL). Three studies used distilled or mineral water as a control group
(CTRL) [9,10,11] and one study compared the use of chlorhexidine
digluconate (CHX) 0.2% with the coconut oil pulling intervention [8].
The oral hygiene adjustment differed for each study. Two advised oil
pulling for 10 min [9,10], however one of these advised no toothbrushing
[9]. One study advised oil pulling for 15–20 min [10] whereas the other
study had no time limit set but advised oil pulling to be carried out twice
daily [11]. Apart from one study conducted over 7 days [9], the duration
of the remaining studies were all 14 days [8,10,11].
3.2.1. Plaque index score
Two studies reported data on the plaque index score [8,9]. Nagilla
et al. found a statistically significant difference between the control
group (CTRL) and coconut oil pulling intervention (OIL) (p¼<0.001).
Sezgin et al. found no significant difference in the reduction of plaque
index score between the OIL group and chlorhexidine group (CHX) after
14 days (p¼0.09).
3.2.2. Gingival index score
One study assessed gingival index score [8]. Sezgin et al. found no
significant difference in the gingival index score between the OIL group
and CHX after 14 days (p¼0.286).
3.2.3. Bleeding on probing
One study assessed bleeding on probing [8]. Sezgin et al. found no
significant difference in the gingival index score between the OIL group
and CHX after 14 days (p¼0.225).
3.2.4. Stain index
One study assessed stain index [8]. Sezgin et al. found the CHX group
exhibited higher scores (increased tooth staining) compared to OIL and
the differences between the two groups were statistically significant (p¼
0.0002).
3.2.5. Salivary Streptococcus mutans count
One study assessed salivary Streptococcus mutans count [11]. Jau-
hari et al. found there was no statistical difference for both the OIL
Table 1. Quality assessment for the included studies using the Oxford Centre for Evidence-based Medicine –Levels of Evidence criteria [7].
Author(s) Study Type Level of Evidence
Jauhari et al., 2015 RCT 2b
Kaushik et al., 2016 RCT 2b
Nagilla et al., 2017 RCT 2b
Sezgin et al., 2019 RCT 2b
J. Woolley et al. Heliyon 6 (2020) e04789
3
group (p¼0.967) and control group (p¼0.796) with regards to the
change in Streptococcus mutans count after 14 days. In addition, there
was no statistically significant difference between these two groups (p
¼0.743).
3.2.6. Salivary bacterial colony count
Two studies reported the total salivary bacterial colony counts [10,
11]. Jauhariet al. found there was reductions in the bacterial colonycount
for the OIL group, however there was no statistically significant difference
Table 2. Full text articles excluded and reason for exclusion.
Author(s) Year Reason for Exclusion
Vadhana et al. [18] 2019 Incorrect intervention
Sheikh and Iyer [19] 2016 Incorrect intervention
Gbinigie et al. [20] 2016 Review
Puri [21] 2015 Opinion paper
Telles et al. [22] 2009 Letter
Penmetsa and Pitta [23] 2019 Incorrect intervention
Kandaswamy et al. [24] 2018 Incorrect intervention
King [25] 2018 Review
Naseem et al. [26] 2017 Review
Shanbhag et al. [2] 2017 Review
Howshigan et al. [27] 2015 Incorrect intervention
Kuroyama et al. [17] 2015 Incorrect intervention
Sood et al. [28] 2014 Incorrect intervention
Oklahoma Dental Association [29] 2014 Letter
Singh et al. [13] 2011 Review
Asokan et al. [30] 2011 In vitro study
Asokan et al. [31] 2008 Incorrect intervention
Karthikeson [32] 2019 Survey
Jeevan et al. [33] 2019 Review
Swathi and Maragathavalli [34] 2018 Review
Seher et al. [35] 2017 Incorrect intervention
Mathewand Sankari [36] 2014 Review
Lakshmi et al. [37] 2013 Review
Mittal et al. [38] 2018 Incorrect intervention
Asokan et al. [30] 2011 Incorrect intervention
Asokan et al. [39] 2009 Incorrect intervention
Wong et al. [15] 2018 Incorrect intervention
Asokan [40] 2008 Letter
Shetty [41] 2019 Unable to access journal
Kablian and Ramamurthy [42] 2016 Incorrect intervention
Halim et al. [43] 2014 Full text unavailable
Shino et al. [44] 2015 In vitro study
Lavine et al. [45] 2018 In vitro study
Dewi et al. [46] 2017 In vitro study
Shanbhag [2] 2017 In vitro study
Peedikayil et al. [47] 2016 Non-RCT
Zope [48] 2017 Non-RCT
Peedikayil et al. [3] 2015 Non-RCT
Figure 2. Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
J. Woolley et al. Heliyon 6 (2020) e04789
4
with this result (p¼0.097). No comparison was reported with the control
group. In comparison, Kaushik et al. found with regards to the reduction in
the total bacterial colony count, there was a statistically significant dif-
ference for the OIL group (p¼0.0256). In addition, there was a statistically
significant difference between the reduction in total salivary bacterial
colony count between the OIL and control groups (p¼0.05).
3.3. Risk of bias and review quality assessment
There was a significant variation in the presence of bias within all four
studies (Figures 2and 3). Due to the nature of the intervention and co-
conut oil having a distinct taste and consistency, it was expected that a
number of the studies would have a high-level of risk of performance
bias. Only one study demonstrated that measures had been sufficiently
undertaken to adequately reduce this level of risk regarding the blinding
of participants [9]. Selection bias was another area of concern. It was
unclear in three studies whether the allocation of groups had been
concealed.
The quality of the studies was assessed using the Oxford Levels of
Evidence (Figure 3). All RCTs were deemed to be of low quality due to the
to the lack of statistical analysis of the results including no odds ratios or
confidence intervals. For this reason, one cannot be confident that the
results of the interventions are near the true value for the outcomes,
across all four studies. All studies reported no conflict of interest and all,
bar one [8], had no source of funding (Figure 1).
4. Discussion
In Ayurvedic medicine, oil pulling is claimed to cure more than thirty
systemic diseases ranging from diabetes to asthma [12]. It has been used
extensively for many decades in the Indian subcontinent and now has a
global presence. Oil pulling therapy is traditionally carried out using
sesame oil, but other oils such as sunflower and coconut oil have been
advocated [13]. Other systematic reviews have considered the effect of
sesame and alternative oils on dental hygiene and oral health, however to
the best of our knowledge, this is the first systematic review to assess the
effect of coconut oil for oil pulling on oral health.
The results from the included randomised controlled trials demon-
strated evidence that coconut oil pulling has a significant effect on plaque
index score when compared to the control group. The evidence for co-
conut oil pulling having a reduction in salivary bacterial colony count
was variable. Both studies detected a reduction, however there was no
reported statistical difference in one. With regards to salivary Strepto-
coccus mutans count, the evidence suggests that coconut oil pulling has
no change when compared to a control after two weeks of the
intervention.
One study compared the use of chlorhexidine mouthwash, a broad-
spectrum antiseptic used frequently in the management of gingivitis
and periodontitis [14]. The evidence suggests that chlorhexidine
mouthwash use has no statistical difference compared to the use of co-
conut oil pulling for plaque score; gingival index score and
bleeding-on-probing. Predictably, there was a significant difference in
staining when comparing these two groups. As a well understood side
effect of chlorhexidine, hard-tissue staining poses an issue for both pa-
tients and for dental care professionals with regards to removal. Chlor-
hexidine mouthwash has been reported to have a number of other
adverse effects, most commonly taste disturbance; hypersensitivities and
mucosal soreness or irritation [14]. Supporters of coconut oil pulling may
see these adverse effects of using chlorhexidine mouthwash as another
reason to promote the use of coconut oil; unfortunately none of these
effects were demonstrated in the included studies, most likely due to the
short study durations.
Figure 3. Risk of bias summary: review authors' judgements about each risk of
bias item for each included study.
Table 3. Study characteristics from studies included in systematic review.
Author(s) Design nAge range Mean age Study duration Intervention Oral hygiene adjustment Control Outcomes Measured Funding
Jauhari et al.,
2015
RCT 52 6–12 years NR 14 days Coconut oil Oil pulling
twice daily
Distilled water.
Mouthrinse twice daily
1. Oral microbial levels
2. S. Mutans level in saliva
None
Kaushik et al.,
2016
RCT 60 18–22 years 20 14 days Coconut oil Oil pulling
10ml for 10 min
Distilled water.
Mouthrinse
5ml for 1 min
1. Microorganism
total colony
-forming units
None
Nagilla et al.,
2017
RCT 40 18–22 years 20.5 7 days Coconut oil Oil pulling
10–15ml for 10 min.
No toothbrushing
Mineral water.
Mouthrinse.
No toothbrushing
1. Plaque index None
Sezgin et al.,
2019
RCT 30 18–52 years 26.3 14 days Coconut oil Oil pulling
10ml twice daily for
15–20 min
Chlorhexidine 0.2%.
Mouthrinse
10ml twice daily for 30 s
1. Plaque index
2. Stain index
3. Gingival index
4. Bleeding on probing
Baskent University
Research Fund, Turkey
J. Woolley et al. Heliyon 6 (2020) e04789
5
No studies included in this review reported on the adverse effects of
oil pulling. Throughout the full-text screening, a small number of articles
described cases of lipid pneumonia in patients who regularly oil pulled
[15,16,17]. However, in all case reports, the patients were reported as
suffering with swallowing dysfunctions and or were at a high risk of
aspiration. Nevertheless, as there has been no definitive evidence pub-
lished on this adverse effect, careful consideration is needed.
The results from this review must be interpreted with caution. Evi-
dence has been concluded from a small sample of RCTs that are not well
powered. The small sample sizes and short durations of interventions
could have affected the sensitivity of the results and thus drawn
misleading conclusions.
Furthermore, inter-study variability in methodology made it for
difficult for grand comparisons to be made. Coconut oil was used as the
method of intervention for all studies. In three studies, this was compared
to water as a control, and the other study used chlorhexidine. Only one
study detailed clearly the complete oral hygiene adjustment during the
study period and documented the advice given to participants to stop
brushing for the study duration [9]. It was unclear what other oral hy-
giene habits were enforced in the other three studies.
A robust search strategy was carried out adhering to PRISMA guide-
lines however we recognise a number of limitations of this systematic
review. Firstly, due to the small sample size and short duration of the
studies reported, it is unclear whether these results can be extrapolated
and applied to long-term effects. In addition, three of the studies were
conducted in the same country; India, and all were conducted in the
Asian continent and it is therefore not appropriate to apply these findings
other regions. In addition, due to the nature of the differences in inter-
study methodology, quantitative pooling of results was unachievable
and therefore distinct correlations and corresponding conclusions cannot
be made.
Secondly, despite the measures in place to avoid bias within these
studies, owing to the very nature of the interventions with variable co-
conut oil having a distinct taste, colour and consistency, complete subject
blindness is difficult and therefore with both selection and performance
biases, results may have been misleading. This was evident from the
assessment of the risk of bias (Table 1,Figure 2). Finally, despite a
comprehensive search strategy, it may be the case that other randomised
controlled trials exist that have not been published.
The authors believe that additional randomised controlled trials are
necessary to determine whether coconut oil pulling improves oral health
and if so; the mechanism of action. The authors advocate, in general, that
the following rules should be applied for future studies:
Studies should be conducted in multiple centres with a larger sample
population.
Outcomes should be assessed with standardised reproducible scales
and should be calibrated amongst the clinicians involved in the study.
Studies should be carried out and described in sufficient detail to
allow an assessment of comparable groups.
Common, quantifiable and clinically relevant data (time of inter-
vention, oral hygiene adjustments, specific outcomes, treatment
acceptability and participant satisfaction) should also be included in a
sufficiently detailed manner.
A longer study duration should be used.
A follow-up period is essential to identify a predictable treatment
effect.
5. Conclusion
This is the first systematic review reporting the effect of coconut oil
when used for oil pulling to improve dental hygiene and oral health.
This study has observed and highlighted the absence of high-quality
evidence in the literature subjected to bias. Consequently, it is there-
fore difficult to determine whether oil pulling with coconut oil has an
actual beneficial effect. It is promising to see beneficial outcomes and
the authors hope this review will encourage further research to a higher
quality in the future. To conclude, the available data suggests that a
larger number of well-designed randomised controlled trials are
essential to determine the impact of oil pulling with coconut oil on oral
health.
Table 4. Reported outcomes from studies included in systematic review.
Author(s) nPI GI BOP SI Salivary SM count Salivary BC count
Jauhari et al. 52 NR NR NR NR Change in mean score
OIL: 0.54 (0.967); p¼0.068
CTRL: 0.41 (0.796)
p¼0.078
Comparison of change in
between groups p¼0.743
Change in mean score
OIL: 10 (4.34); p¼0.097
CTRL: -2.31 (1.15)
p¼0.291
Kaushik
et al.
60 NR NR NR NR NR Change in mean score
OIL: 29.70 (54.82);
p¼0.0256
CTRL: 0.90 (1.17)
p¼0.0027
Comparison of change
in between
groups p¼0.05
Nagilla et
al.
40 Post intervention
score OIL: 1.16 (0.28)
CTRL: 1.50 (0.37) p¼<0.001
NR NR NR NR NR
Sezgin et al. 30 Post intervention
score OIL: 1.67 (0.24)
CHX: 1.61 (0.20)
p¼0.09
Post intervention
scoreOIL: 0.60 (0.21)
CHX: 0.67 (0.25)
p¼0.286
Post intervention
score OIL: 0.09 (0.30)
CHX: 0.01 (0.09)
p¼0.225
Post intervention
scoreOIL: 0.21 (0.13)
CHX: 0.47 (0.27)
p¼0.0002
NR NR
Abbreviations: n (number of participants); PI (plaque index); GI (gingival index); SI (stain index); SM (Streptococcus mutans); BC (bacterial colony); NR (not reported);
OIL (coconut oil pulling group); CTRL (control group); CHX (chlorhexidine digluconate).
Bold: Statistically significant (0.05).
J. Woolley et al. Heliyon 6 (2020) e04789
6
Declarations
Author contribution statement
J. Woolley and T. Gibbons: Conceived and designed the experiments;
Performed the experiments; Analyzed and interpreted the data; Wrote
the paper.
K. Patel and R. Sacco: Analyzed and interpreted the data; Wrote the
paper.
Funding statement
This research did not receive any specific grant from funding agencies
in the public, commercial, or not-for-profit sectors.
Competing interest statement
The authors declare no conflict of interest.
Additional information
No additional information is available for this paper.
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