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A study of anti-plaque efficacy and taste perception of Calendula officinalis mouth rinse

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Introduction: An ideal mouth rinse must have an acceptable taste and very efficient antiplaque activity. Herbal mouth rinse (Plandula®), containing extracts of Calendula officinalis and other specified herbs, is widely cultivated as a herb. It is a remarkable healing agent and even useful to act as homeopathic remedies. Previous studies have compared this product with placebo; however, comparison against chlorhexidine have not been conducted thus far. Aim of this research was to analyse the efficacy of Calendula in Plandula® for controlling dental plaque and the acceptability of its taste in comparison with chlorhexidine. Methods: A double-blind, 3-day plaque regrowth, crossover, clinical study was conducted towards 16 volunteers participated in two periods, three days each, with modified oral hygiene practices through an intervening washout period of 4 days. At the commencement of each period, the participants received oral prophylaxis. They used the allocated mouth rinse and brushed teeth without toothpaste in all of the tooth surfaces, except palatal and lingual over three days. On the fourth day, the subjects were returned for plaque index measurement only on the palatal and lingual surfaces by the Quigley Hein index (modified by Turesky). The participants rinsed with 10 ml of allocated mouth rinse three times daily for 30 seconds after tooth brushing. The participants followed the same steps during the second period using the alternate mouth rinse. They were also asked to taste both mouth rinses and evaluate with a Visual Analogue Scale (VAS).Results: Median plaque score for Plandula® mouth rinse was slightly higher compared to chlorhexidine but not statistically significant, with the p-value=0.636 (p>0.05). The mean VAS scale score for Plandula® taste perception was lower than the chlorhexidine, and statistically significant (p-value=0.01; p
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190
Padjadjaran Journal of Dentistry. 2020;32(3):190-196.
p-ISSN: 1979-0201; e-ISSN: 2549-6212; Available from: http://jurnal.unpad.ac.id/pjd/article/view/29402
DOI: 10.24198/pjd.vol32no3.29402
Submission: Sep 10, 2020; Accepted: Nov 25, 2020; Published online: Nov 30, 2020
A study of anti-plaque ecacy and taste perception of Calendula
ocinalis mouth rinse
Erry Mochamad Arief1*, Zaridah Zainal Abidin1, Mohaideen Sitheeque2, Md Azman
PKM Seeni Mohamad3
1Department of Periodontics, School of Dental Sciences Universiti Sains Malaysia, Malaysia
2Department of Oral Medicine, School of Dental Sciences Universiti Sains Malaysia, Malaysia
3Department of Craniofacial and Oral Biology, School of Dental Sciences Universiti Sains Malaysia,
Malaysia
ABSTRACT
Introduction: An ideal mouth rinse must have an acceptable taste and very ecient antiplaque activity.
Herbal mouth rinse (Plandula®), containing extracts of Calendula ocinalis and other specied herbs,
is widely cultivated as a herb. It is a remarkable healing agent and even useful to act as homeopathic
remedies. Previous studies have compared this product with placebo; however, comparison against
chlorhexidine have not been conducted thus far. Aim of this research was to analyse the ecacy of
Calendula in Plandula® for controlling dental plaque and the acceptability of its taste in comparison with
chlorhexidine. Methods: A double-blind, 3-day plaque regrowth, crossover, clinical study was conducted
towards 16 volunteers participated in two periods, three days each, with modied oral hygiene practices
through an intervening washout period of 4 days. At the commencement of each period, the participants
received oral prophylaxis. They used the allocated mouth rinse and brushed teeth without toothpaste
in all of the tooth surfaces, except palatal and lingual over three days. On the fourth day, the subjects
were returned for plaque index measurement only on the palatal and lingual surfaces by the Quigley
Hein index (modied by Turesky). The participants rinsed with 10 ml of allocated mouth rinse three times
daily for 30 seconds after tooth brushing. The participants followed the same steps during the second
period using the alternate mouth rinse. They were also asked to taste both mouth rinses and evaluate
with a Visual Analogue Scale (VAS).Results: Median plaque score for Plandula® mouth rinse was slightly
higher compared to chlorhexidine but not statistically signicant, with the p-value=0.636 (p>0.05). The
mean VAS scale score for Plandula® taste perception was lower than the chlorhexidine, and statistically
signicant (p-value=0.01; p<0.05). Conclusion: Plandula® mouth rinse that contain calendula ocinalis
comparable with chlorhexidine in controlling dental plaque accumulation, with an acceptable taste.
Keywords: Calendula ocinalis, chlorhexidine, plaque regrowth, taste perception.
*Corresponding author: Erry Mochamad Arief, Department of Periodontics, School of Dental Sciences Universiti Sains
Malaysia, Malaysia. Health Campus, Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia, 16150. Phone:
+60133269785; Email: erry@usm.my
191
A study of anti-plaque ecacy and taste perception of Calendula ocinalis mouthrinse (Arief et al.)
INTRODUCTION
The biolm in the oral cavity known as a bacterial
plaque contains of complex organised microbial
community is formed naturally on the exposed
surface of teeth. The metabolism and colonisation
of bacteria is in fact the primary cause of dental
caries1, gingivitis, periodontitis2, peri-implant
infections3 and stomatitis4,5 condition caused by
bacterial plaque can be controlled by means of
mechanical or chemical. The use of mouth rinse
as a cleansing chemical agent, ideally due to its
ability to reach all the surface of teeth. It can
be from a very simple aqueous solution to a
very complex with addition of avor, colour or
any other additives to make it acceptable in the
general population.6
Nowadays, mouth rinse was formulated with
antimicrobial. Broad-spectrum antimicrobials,
such as chlorhexidine, essential oils, and
cetylpyridinium chloride (CPC), are commonly
formulated in mouth rinses. Chlorhexidine,
with formula C22H30Cl2N10 is still considered a
gold standard mouthrinse with the ability to
reduce plaque successfully.7 Based on a clinical
study conducted by Welk et al.8, 0.12% has
signicantly better in reducing plaque compared
to polyhexamethane biguanide (PHMB) but has
no signicant dierent with triclosan. However,
chlorhexidine is well known for the extrinsic
staining as the long-term eect.9
Based on today scenario, people now
related both their oral health and overall medical
health. In response to that many personal mouth
rinse have been marketed to oer variety of
natural mouth rinse to help consumer realise and
maintain their whole-body health without articial
pharmaceutical. Modern society nowadays realises
that natural-based mouth rinse, such as lime peel
essential oil-based mouth rinse is relatively safer
to use for a long term period on a daily basis.10
Calendula ocinalis is the experimental
sample in this study, is widely cultivated as a
herb it is a remarkable healing agent and even
useful to act as homeopathic remedies. Its extract
has been used in Europe since before the 12th
century primarily as a topical antiinammatory
agent.11 Recently, any thesis reviewed about the
eectiveness o Plandula® mouthrinse containing
the extract of Calendula ocinalis, provide a
signicant benet in reducing plaque and gingival
inammation.5 An in vitro study done by Haajee
et al.12, showed that the herbal mouthrinse
containing extract of Calendula ocinalis were
eective in inhibiting oral bacteria thereby it is
reecting its usefulness in reducing plaque and
gingival inammation although less potent than
the chlorhexidine.12
The purpose of the present study was
to compare plaque reducing ecacy and taste
perception between Plandula® mouthrinse
containing extract of 0.64% Calendula ocinalis
and Diam–C containing 0.12% chlorhexidine.
METHODS
Sixteen volunteers, 12 males and 4 females
were participated, with a mean age of 28 years
old. They received a written explanation of the
background of the study, its objectives and their
involvement (Figure 1).
The participants were required to fulll the
following criteria’s such as aged between 23 - 48
years-old, minimum of 25 scorable tooth (with
no restoration on lingual and palatal surfaces,
partial dentures, orthodontic banding or wires)
and participants with healthy oral and periodontal
condition with clinical parameter were bleeding on
probing (BOP) ≤10% and probing depth ≤3 mm and
tooth mobility <grade 1.In addition, participants
allergic to any of the mouthrinse components
or on any antibiotic, pregnant, with systemic
diseases such as diabetes and any adverse medical
history or long-term medication were excluded
from the study.
All participants who fulll the criteria were
signing an informed consent prior to the study.
The ethical for the present study was approved
by the School of Medical Sciences Universiti Sains
Malaysia Ethics Committee with the approval
number of (USMKK/PPP/JEPeM (224.4.(3.10)).
This clinical trial was a double blind,
crossover, randomised, consisting of two periods
intervention, each period was 3-days duration that
were separated by 4-days washout period. Two
dierent mouthrinse were compared (Figure 2):
Mouthrinse A: Plandula® mouthrinse containing
the extract of Calendula ocinalis (0.64%)
(Figure 3); Mouthrinse B: Diam-C containing
chlorhexidine gluconate (0.12%) (Figure 4).
192
Padjadjaran Journal of Dentistry. 2020;32(3):190-196.
Figure 1. The study ow chart
Figure 2. Mouth rinse A: Plandula®
mouthrinse containing the extract
of Calendula ocinalis (0.64%)
Figure 3. Mouth rinses B : Diam C Figure 4. Mouthrinse A and B
(bottles were covered with the black
plastic and were kept in the same kind
of bottle)
Volunteer
Inclusion:
1. Age: 23-48 years old
2. With 25 scorable tooth
3. Healthy oral and periodontal condition
Exclusion:
4. Allergic to any of the mouthrinse components or on any antibiotic
5. Pregnant
6. With systemic diseases such as diabetes and any adverse medical history or long-term medication
Flow chart
Volunteer
N=16
Mouthrinse A for 3 days plaque score
taste perception
N=8
Washout 4 days
Analysed
N=16
Mouthrinse A for 3 days plaque score
taste perception
N=8
Mouthrinse B for 3 days plaque
score taste perception
N=8
Mouthrinse B for 3 days plaque
score taste perception
N=8
193
A study of anti-plaque ecacy and taste perception of Calendula ocinalis mouthrinse (Arief et al.)
Figure 5. All teeth present in mandibular
were assessed except 3rd molars
Figure 6. All teeth present in maxillary
were assessed except 3rd molars
Due to the double-blind design, all bottles
were covered with the black plastic and were kept
in the same kind of bottle (Figure 4). Two dental
surgery assistances were included to assist along
the study. The assessor and the participant did not
know the allocated mouthrinse until completion
of the study. At the baseline, of each test period,
all participants received a dental prophylaxis to
remove plaque, calculus and stain from all tooth
surfaces to make plaque become zero. They were
randomly assigned to the allocated mouthrinse.
All participants were randomised for 2 dierent
allocated mouthrinse using randomisation plan
generator.13
The instruction for the allocated mouthrinse
was given to all participants at the chairside.
All participants were instructed to use 10 ml of
allocated mouthrinse for 30 second three times
daily which was done after brushing their teeth, in
the morning after breakfast, once in the afternoon
after lunch and once at night, before they went
to sleep. The toothbrushing was done without
toothpaste on buccal/facial and occlusal only.
During the each of test period, all participants
were instructed to refrain from using any other
oral hygiene procedure. On the fourth day, the
participants returned for measurement of plaque
on the palatal and lingual surfaces by Quigley Hein
Index (modied by Turesky) (Figure 5 and 6)9.
Plaque was assessed then, and all the
measurement was done by an examiner who was
blinded to the allocated mouthrinse. Following
the measurement, another dental prophylaxis was
done for all teeth. At the end of rst test period,
the allocated mouthrinses were collected. To
check for compliance, the participants were asked
to tick the time of use of the mouthrinse onto a
calendar record chart. After that, all participants
entered a 4-day washout phase to minimize
carry-over eects and habitual oral hygiene
procedures were resumed. The second period of
another 3 days commenced after an intervening
4-day washout period. The same procedures were
prescribed to the participants but using the other
allocated mouthrinse.They were also asked to
taste both mouthrinses and evaluated them on a
Visual Analogue Scale (VAS) of 0 to 10, 0 being plain
taste and 10 for bitter taste.The reproductivity
was assessed before start of study, in a total of
110 surfaces from one participant, the plaque
scorewas taken twice and repeated at 90 minutes
after. The dierence in repeated recording of 0, ±
1, ±2 was calculated. Level of reproducibility was
set at 80% agreement.
Statistical analysis
Statistical analysis was carried out using the
statistical package for social science system
(SPSS) version 18. Calculation was performed
based on percentage of agreement (0 and 1).
Level of reproducibility was set at the 80%
agreement. Comparison between test (Plandula®)
and Chlorhexidine groups, Paired sample t-test
was employed where the signicance level was at
the level p ≤ 0.05.
RESULTS
Demographic characteristic of the participants
is presented in Table 1. The reproducibility
results were shown a total of 90 out of 110
surface had 0 score repeated recordingg, which
gave the percentage of 82% (Table 2). Thus, the
reproducibility percentage agreement of above
80% was achieved. All participants were shown
compliance to the instruction and no adverse eect
were reported during this study. No signicant
dierence noticed in the plaque scores between
Calendula ocinalis and chlorhexidine mouth
rinse, whereas, signicant dierence noticed for
the taste perception between both mouth rinses
(Table 3).
194
Padjadjaran Journal of Dentistry. 2020;32(3):190-196.
DISCUSSION
This study was assessing the 3-days plaque regrowth
model in evaluating the plaque inhibitory eect
of Plandula® mouthrinse and taste perception
between Plandula® mouthrinse containing
extract of 0.64 % Calendula ocinalis and Diam
C containing 0.12% chlorhexidine. The methods
that was used in this were adopted from various
study before. Many studies previously have used
3 day - plaque regrowth model to assess various
eect of mouthrinse and this period is enough to
allow plaque to accumulate freely. A study done
by Simonsson et al.15, compared heavy and light
plaque formers which eventually result in a large
dierence based on several factors.
In this study, the plaque index was assessed
with Quigley and Hein, modied by Turesky9 which
is reliable and also sensitive in term of more
criteria or dierentiation at cervical area, from
only 1 criteria in Plaque Index16 to 3 criteria in
Quigley and Hein, modied by Turesky9, thus, it is
more accurate to assess the cervical area covered
by plaque.16In this study results shown that no
signicant dierence noticed in the plaque scores
between Calendula ocinalis and chlorhexidine.
Yuso17 compared mouthrinse containing the
extract of Calendula ocinalis with the plain
water result in the signicant plaque reducing
ecacy. Apart from that, a research of herbal
rinse by Haajee et al.12 containing extract of
Calendula ocinalis showed it was more eective
than the essential oil rinse in inhibiting the growth
of oral bacteria in vitro although it is less potent
than the chlorhexidine.
This result is also supported by our ndings
on ecacy of Calendula ocinalis.In this study
shown there was signicant dierence noticed for
the taste perception between both mouthrinses.
The taste of mouthrinse containing the extract
of Calendula ocinalis were appreciated better
maybe due to absence of alcohol. A study
conducted by Van Strydonck et al.5 comparing
a 0.12% chlorhexidine free alcohol and 0.2%
chlorhexidine containing of 11.8 % ethanol showed
a signicant dierent, which was better taste
acceptability for non-alcohol. Similarly, a study of
Ernst et al.18, suggested that approximately of 33%
participants claimed that the alcohol-contained
chlorhexidine has a poor taste. This was in
Table 1. Demographic characteristic of the participants
Participants characteristics (n=16)
Age: range, mean 20-50, 28 years old
Gender, n (%)
Male 12
Female 4
Scorable tooth
≥25 tooth 100%
<25 tooth 0%
Bleeding on probing (%)
≤10 % 100%
>10% 0%
Pocket depth (%)
≤3 mm 100%
>3mm 0%
Allergic to any of the mouthrinse
components or on any antibiotic 0%
Pregnant 0%
With systemic diseases such as
diabetes and any adverse medical
history or long-term medication
0%
Table 2. Reproducibility
Dierence
between repeated
recordings
Number of surfaces Percentages
0 90 81.8
±1 20 18.2
Total 110 100
0 = no dierent, 1= dierent ≥1; Calculation based on
percentage; Level of reproducibility was set at 80%
agreement
Table 3. The mean (SD) of plaque index and taste perception
Group NMean plaque
index (SD)
Taste
perception*
Plandula
mouthrinse 16 1.66 (0.54) 3.00 (1.21)
Chlorhexidine
mouthrinse 16 1.43 (0.52) 6.81 (1.51)
p-value 0.636 0.01
Paired sample t-test was employed where the signicance
level was at the level p 0.05; *Statistically signicantly
dierent
Figure 7. The mean of plaque score and taste perception
195
A study of anti-plaque ecacy and taste perception of Calendula ocinalis mouthrinse (Arief et al.)
agreement with our ndings on taste perception of
Calendula ocinalis. So our suggestion for better
taste, mouthrinse should not contain an alcohol.
Certain limitations were noted. The colour and
taste could not be similar. The chemicals of both
mouthrinse were neither added nor modied as
this could change or aect the therapeutic value
of respective mouthrinse. In order to minimize
the limitation, the bottles were covered with
black plastic and the taste of chemicals are
dierent, this may provoke participants towards
the acceptability of certain mouthrinse that may
later aect the compliance which consequently
aect in the result.
As this matter being brought, all participants
were reminded to follow the standardisation
from the beginning and the incompliance were
considered as dropout. Rinsing calendar were
glued together to check the compliance and
instruction were sent prior to each appointment.
Another limitation is smal amount of participants
were taken due to time restriction and some
diculty to get more participants. All participants
were screened to pass the criteria listed. Initially,
there were more than two participants were
eliminated during the screening following the
exclusion protocol.
The participant also came only from one
source, which was the patients who attend the
Universiti Sains Malaya Hospital, and might not
consider representing the general population.
However, the participants were randomly selected
from the age of 23-48 years old to reduce the
conscious bias and to minimise the unconscious
bias for unknown factor.1 Other limitation was the
Hawthorne eect, that the participants tend to
rinse more than daily practice.
A crossover design of this study also made
it possible to create a carry over eect, which
must always be considered especially if an
antimicrobial agent is applied. It is important
for the participants to returned to their original
status before proceeding to the next stage. This
carry over eect can be overcome by providing a
washout period of standard oral hygiene which is
thought to be sucient to neutralise the previous
therapeutics eect. A longer washout period is
preferable and design should be balanced for
residual eects, at least from the preceding
treatment period.14
CONCLUSION
Calendula in Plandula® mouth rinse containing
0.64% Calendula ocinalis is more eective
in inhibiting plaque formation, and it was
comparable with 0.12% chlorhexidine mouth rinse.
Plandula® also has a better taste compared to the
chlorhexidine mouth rinse.
ACKNOWLEDGMENT
This study was supported by Farabi Herbal
Industries Sdn. Bhd.
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... Besides the antibacterial activity, another important aspect is mouthwashes is the taste. A clinical study by Arief et al. demonstrated that a commercial preparation with marigold extract -Plandula® -resulted in obtaining a slightly higher average plaque index compared to the use of CHX, but statistically insignificant [25]. ...
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People's health is favorable impacted by medicinal plants. In addition to their conventional purpose, many isolated chemicals from herbs have beneficial therapeutic characteristics for treating various disorders. In this review, the usage of Calendula officinalis will be discussed in relation to pathologies that affect the oral cavity, such as dental caries, gingivitis or periodontitis. Calendula officinalis extract is able to decrease inflammation through pro-inflammatory cytokines down modulation and promotes antioxidant and immunomodulatory effects-as a result of the presence of polysaccharides and flavonoids in the plant-the main biological actions that make it effective in oral healthcare.
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