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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 7  |  Issue : 1  |  Page : 21-24

Evaluation of clinical effificacy of Terminalia chebula inplaque-induced gingivitis: A randomized control trial


Department of Periodontics, Vivekanandha Dental College for Women, Tiruchengode, Namakkal, Tamilnadu, India

Date of Web Publication30-Jun-2017

Correspondence Address:
P S Viola Esther
A 10, Nakshatra Appartments, Puliyakulam, Coimbatore - 641 045, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijmd.ijmd_9_17

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  Abstract 

Introduction: Plaque control is fundamental to the prevention and management of periodontal diseases. However, most of the individuals do not practice plaque removal in an adequate manner. Hence, there is a need for an antiplaque agent that can be used on a daily basis without the side effects of antibacterial chemicals. The aim of the study is to evaluate the clinical efficacy of Terminalia chebula in patients with chronic gingivitis.
Materials and Methods: Eighty patients, 18–40 years of age, diagnosed with chronic generalized gingivitis were selected and randomly divided into two groups. Group I underwent oral prophylaxis alone whereas Group II underwent oral prophylaxis and advised to do gingival massage by T. chebula powder. Clinical evaluation was done using plaque index (PI), gingival index (GI), and gingival bleeding index (GBI) at baseline and after 1 month.
Results: Gingival massage with T. chebula powder showed a significant reduction in PI, GI, and GBI scores from baseline to 1 month.
Conclusion: T. chebula powder is a useful herbal formulation for plaque control in patients with chronic gingivitis.

Keywords: Antiplaque agents; gingivitis; Terminalia chebula


How to cite this article:
Esther P S, Elanchezhiyan S, Daniel R, Meenalochani T B, Pavithra T, Surya D. Evaluation of clinical effificacy of Terminalia chebula inplaque-induced gingivitis: A randomized control trial. Indian J Multidiscip Dent 2017;7:21-4

How to cite this URL:
Esther P S, Elanchezhiyan S, Daniel R, Meenalochani T B, Pavithra T, Surya D. Evaluation of clinical effificacy of Terminalia chebula inplaque-induced gingivitis: A randomized control trial. Indian J Multidiscip Dent [serial online] 2017 [cited 2017 Aug 18];7:21-4. Available from: http://www.ijmdent.com/text.asp?2017/7/1/21/209282


  Introduction Top


Periodontal disease is a chronic inflammatory disease characterized by a bacterial challenge that can provoke a destructive host response, leading to periodontal attachment loss.[1] There is a direct relationship between plaque levels and development of gingivitis which plays a primary role in the initiation of periodontitis.[2]

Gingival inflammation resolves by effective plaque control which could be achieved using a toothbrush and other oral hygiene aids.[3] However, the human limitations associated with adequate mechanical plaque removal have resulted in gingivitis.[4],[5] The widespread occurrence of gingivitis provides the rationale for supplementing with antigingivitis agents that augment mechanical plaque removal.[6] Although a number of chemical plaque control agents are available, they cause untoward reaction on prolonged usage. Hence, an antiplaque agent that can be used on a daily basis with minimal side effects is essential and in need.

Herbal formulations can provide an option for safe and long-term use.[7],[8]Terminalia chebula” is called the “King of Medicine” in Tibet and is always listed at the top of the list “Ayurvedic Materia Medica” because of its extraordinary power of healing.[9] The whole plant possesses high medicinal value and has been used in the treatment of various ailments from the ancient years. The plant has multiple pharmacological and medicinal activities such as antioxidants, antimicrobial, antidiabetic, hepatoprotective, anti-inflammatory, anticaries, gastrointestinal motility, and wound healing activity.[9]

The powder of T. chebula is a good astringent in loose bleeding gums and also heals ulceration in gums.[10] This study evaluates the short-term clinical effects of T. chebula powder in patients with chronic gingivitis.


  Materials and Methods Top


Eighty patients with chronic gingivitis were selected from the dental outpatient department. patients having at least twenty natural teeth, aged 18–40 years with probing depth <4 mm, and Loe and Silness [11] gingival index (GI) >1 with no clinical attachment loss and radiographic bone loss were included in the study. Approval from the Institutional Ethics Committee was obtained. Informed consent was obtained from all patients.

Patients taking antibiotics, in the past 3 months, with history of systemic diseases and with history of periodontal therapy in the past 6 months, smokers, pregnant and lactating mothers, and patients undergoing orthodontic treatment were excluded from the study. They were assessed for gingivitis utilizing Turesky et al. 1970 plaque index (PI)[12], Loe and Silness 1963 GI,[11] and Ainamo and Bay 1975 gingival bleeding index (GBI).[13]

Each patient was randomly assigned to two groups by lottery method. Group I, forty patients, underwent oral prophylaxis and were demonstrated with modified bass method of brushing.Group II, forty patients, underwent oral prophylaxis and were demonstrated with modified bass method of brushing along with gingival massage by T. chebula powder. They were dispensed with T. chebula powder enclosed in plain white packets to ensure blinding. They were instructed to apply a pea-sized amount of powder to the gingiva, twice daily and to massage gently by finger after regular brushing and to leave it for 5 min before rinsing. Patients were contacted through telephone once in 3 days to ensure their daily use of T. chebula powder and to know about taste, flavor, and any other adverse effect associated with it.

Patients were asked to refrain from all other unassigned forms of oral hygiene, including dental floss, chewing gums, or oral rinses during the study. All the clinical parameters (PI, GI, and GBI) were reevaluated after 1 month for both the groups.

Preparation of Terminalia chebula powder

The fruits of T. chebula were collected, washed, dried and ground to very fine powder (<180 μm) by domestic grinder, and passed through sieve no. 80.

Statistical analysis

Analysis of data was carried out using (IBM SPSS Statistics for Windows, Version 22.0. Armonk, NY: IBM Corp). The values were expressed as mean ± standard deviation. Paired t-test was used for intragroup comparison and unpaired t-test was used for intergroup comparison.


  Results Top


A statistically significant reduction in PI, GI, and GBI was observed using paired t-test in both Group I and Group II between baseline and 1 month as tabulated in [Table 1]. When the reevaluated scores after 1 month were compared between Groups I and II using independent t-test as tabulated in [Table 2], a significant reduction was observed in Group II than Group I.
Table 1: Paired t-test to compare mean values between baseline and 1 month

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Table 2: Independent t-test to compare mean values between groups after 1 month

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  Discussion Top


Plaque is the major etiological factor in gingival and periodontal disease, and mechanical plaque control is undoubtedly the best approach for elimination of plaque,[14] but most of the people do not perform thorough mechanical tooth cleaning. This stimulated the search for chemotherapeutic agents.

Scaling is the first line of treatment and it is an indispensable phase of periodontal therapy in the management of gingivitis and periodontitis. Plaque control after a thorough oral prophylaxis has to be maintained to eliminate or arrest the progression of disease. The inability of the people to maintain a good oral hygiene leads to recurrence of the disease. Therefore, in addition to mechanical plaque removal measures, chemical plaque control measures have also been advocated that can be used as an adjunct to mechanical measures, which together can reduce plaque-associated gingivitis.[15],[16]

The effectiveness of various chemical plaque control agents has been evaluated, but they are associated with adverse effects incapacitating their long-term use. Hence, new formulations with equal efficacy and no adverse effects are required to be evaluated.

Nowadays, people are aware of the detrimental effects of chemicals, and herbal products have captivated their attention. T. chebula is one of the constituents of triphala, and triphala mouthwash has been proven to be an alternative to chlorhexidine,[17] but there are only few studies which evaluated the individual efficacy of T. chebula. In this context, the present study evaluated the effectiveness of T. chebula powder in gingivitis. According to Date and Kulkarni 1995, T. chebula strengthens gingiva, prevents, and treats several diseases of mouth such as dental caries, spongy and bleeding gums, gingivitis, and stomatitis.[18]

In the present study, a significant reduction in PI, GI, and GBI scores was observed after 1 month in Group II than Group I. This study is consistent with Gupta et al.[19] who demonstrated T. chebula mouthwash reduces PI and GBI scores. The positive clinical effects of T. chebula powder can be attributed to its various phytoconstituents. It is fairly rich in tannins (32%) which include gallic acid, chebulic acid, corilagin, ellagic acid, arjunolic acid, and punicalagin.[20] Binding of tannins to the oral tissues is responsible for prolonged action of T. chebula. These tannins provide antibacterial, anti-inflammatory, and astringent properties.[21] There is a significant reduction in PI score because it inhibits sucrose-induced adherence and glucan-induced aggregation which foster the colonization of organism on the surface of the teeth.[22]

T. chebula exhibits antibacterial activity against Gram-positive and Gram-negative bacteria.[23] It is even effective against methicillin-resistant Staphylococcus aureus.[24] The reduction in GI and GBI scores is due to the hemostatic and astringent properties of tannins.[25]T. chebula is an excellent antioxidant. It inhibits free radical-induced hemolysis and nitric oxide release.[20] Chebulinic acid and arjunolic acid present in T. chebula efficiently reduce inducible nitric oxide synthase and cyclooxygenase in lipopolysaccharide-stimulated macrophages. This is responsible for anti-inflammatory action of T. chebula.[26]T. chebula increases the healing process. Biochemical studies revealed increase in total protein, DNA, and collagen contents in the granulation tissue of treated wounds.[27]

In this study, allergic reaction was not observed among the patients using T. chebula powder because T. chebula by itself is an antiallergic.[28] In addition to the above said properties, T. chebula is also anticariogenic, antimutagenic, antianaphylactic, cytoprotective, anticariogenic, hepatoprotective, etc.[20]

In this study, patients were refrained from other forms of oral hygiene such as usage of dental floss, chewing gum, and oral rinses because it may mask the absolute efficacy of T. chebula. To the authors' knowledge, this is the first study to evaluate the efficacy of T. chebula in the form of powder in gingivitis. Hence, this study lacks the comparison with the other studies.

The results of the present study indicate that T. chebula was successful in the improvement of plaque and gingival scores. But by itself cannot be a “stand-alone therapy” in the prevention of plaque-induced gingivitis. It can be used as an adjuvant to mechanical plaque removal.


  Conclusion Top


T. chebula has shown promising results with no side effects in this study. It is abundantly available, easily accessible, economically feasible, and culturally acceptable. Furthermore, their additional effect on inflammatory pathways and antioxidant potential makes them eligible to be used as antigingivitis agents.

Hence, it can be concluded from the present study that T. chebula can be effectively used to augment mechanical plaque removal on a daily basis to prevent periodontal disease. However, further longitudinal studies are needed to confirm the findings.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Page RC. The etiology and pathogenesis of periodontitis. Compend Contin Educ Dent 2002;23 5 Suppl:11-4.  Back to cited text no. 1
    
2.
Loe H, Theilade E, Jensen SB. Experimental gingivitis in man. J Periodontol 1965;36:177-87.  Back to cited text no. 2
    
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Drisko CH. Nonsurgical periodontal therapy. Periodontol 2000 2001;25:77-88.  Back to cited text no. 3
    
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Jeffcoat MK. Prevention of periodontal diseases in adults: Strategies for the future. Prev Med 1994;23:704-8.  Back to cited text no. 4
    
5.
Position paper: Epidemiology of periodontal diseases. American Academy of Periodontology. J Periodontol 1996;67:935-45.  Back to cited text no. 5
    
6.
Ainamo J. Control of plaque by chemical agents. J Clin Periodontol 1977;4:23-35.  Back to cited text no. 6
    
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Mizrahi B, Shapira L, Domb AJ, Houri-Haddad Y. Citrus oil and MgCl2 as antibacterial and anti-inflammatory agents. J Periodontol 2006;77:963-8.  Back to cited text no. 7
    
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Takahashi K, Fukazawa M, Motohira H, Ochiai K, Nishikawa H, Miyata T. A pilot study on antiplaque effects of mastic chewing gum in the oral cavity. J Periodontol 2003;74:501-5.  Back to cited text no. 8
    
9.
Aneja KR, Joshi R. Evaluation of antimicrobial properties of fruit exteacts of Terminalia chebula against dental caries pathogen. Jundishapur J Microbiol 2009;2:105-11.  Back to cited text no. 9
    
10.
Bag A, Bhattacharyya SK, Chattopadhyay RR. The development of Terminalia chebula Retz. (Combretaceae) in clinical research. Asian Pac J Trop Biomed 2013;3:244-52.  Back to cited text no. 10
    
11.
Loe H, Silness J. Periodontal disease in pregnancy. I. Prevalence and severity. Acta Odontol Scand 1963;21:533-51.  Back to cited text no. 11
    
12.
Turesky S, Gilmore ND, Glickman I. Reduced plaque formation by the chloromethyl analogue of Victamine C. J Periodontol 1970;41:41-3.  Back to cited text no. 12
    
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Ainamo J, Bay I. Problems and proposals for recording gingivitis and plaque. Int Dent J 1975;25:229-35.  Back to cited text no. 13
    
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Suchetha A, Bharwani AG. Efficacy of a commercially available multi-herbal formulation in periodontal therapy. J Indian Soc Periodontol 2013;17:193-7.  Back to cited text no. 14
[PUBMED]  [Full text]  
15.
Theilade E, Wright WH, Jensen SB, Löe H. Experimental gingivitis in man. II. A longitudinal clinical and bacteriological investigation. J Periodontal Res 1966;1:1-13.  Back to cited text no. 15
    
16.
Cobb CM. Non-surgical pocket therapy: Mechanical. Ann Periodontol 1996;1:443-90.  Back to cited text no. 16
    
17.
Rana KP, Rana PT, Tyagi S, Hongal S, Nigam M. Is Triphala a Natural Alternative to Chlorhexidine Mouthwash. Int J Curr Res 2016;8:40647-50.  Back to cited text no. 17
    
18.
Date BB, Kulkarni PH. Assessment of Rasa danti in various oral disorders. Ayurveda Res Pap 1995;2:167-75.  Back to cited text no. 18
    
19.
Gupta D, Gupta RK, Bhaskar DJ, Gupta V. Comparative evaluation of Terminalia chebula extract mouthwash and chlorhexidine mouthwash on plaque and gingival inflammation – 4-week randomised control trial. Oral Health Prev Dent 2015;13:5-12.  Back to cited text no. 19
    
20.
Prakash Chandra Gupta. Biological and pharmacological properties of Terminalia chebula Retz. (Haritaki) – An overview. Int J Pharm Sci 2012;4 Suppl 3:62-8.  Back to cited text no. 20
    
21.
Naik GH, Priyadarsini KI, Naik DB, Gangabhagirathi R, Mohan H. Studies on the aqueous extract of Terminalia chebula as a potent antioxidant and a probable radioprotector. Phytomedicine 2004;11:530-8.  Back to cited text no. 21
    
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Pradeep AR, Agarwal E, Bajaj P, Naik SB, Shanbhag N, Uma SR. Clinical and microbiologic effects of commercially available gel and powder containing Acacia arabica on gingivitis. Aust Dent J 2012;57:312-8.  Back to cited text no. 22
    
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Malekzadeh F, Ehsanifar H, Shahamat M, Levin M, Colwell RR. Antibacterial activity of black myrobalan (Terminalia chebula Retz) against Helicobacter pylori. Int J Antimicrob Agents 2001;18:85-8.  Back to cited text no. 23
    
24.
Sato Y, Oketani H, Singyouchi K, Ohtsubo T, Kihara M, Shibata H, et al. Extraction and purification of effective antimicrobial constituents of Terminalia chebula RETS. against methicillin-resistant Staphylococcus aureus. Biol Pharm Bull 1997;20:401-4.  Back to cited text no. 24
    
25.
Muhammad S, Khan BA, Akhtar N, Mahmood T, Rasul A, Hussain I, et al. The morphology, extractions, chemical constituents and uses of Terminalia chebula: A review. J Med Plants Res 2012;6:4772-5.  Back to cited text no. 25
    
26.
Cheng HY, Lin TC, Yu KH, Yang CM, Lin CC. Antioxidant and free radical scavenging activities of Terminalia chebula. Biol Pharm Bull 2003;26:1331-5.  Back to cited text no. 26
    
27.
Chattopadhyay RR, Bhattacharyyr SK. Terminalia chebula: An update. Pharmacogn Rev 2007;1:151-6.  Back to cited text no. 27
    
28.
Mukherjee PK, Rai S, Bhattachaeyga S, Debrath P, Biswas JK, Jana U, et al. Clinical study of Triphala. A well known phytomedicine from India. Int J Pharm Technol 2006;5:51-4.  Back to cited text no. 28
    



 
 
    Tables

  [Table 1], [Table 2]



 

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