Effect of herbal mouthrinses on dental plaque formation and gingival inflammation: A systematic review

Dental applications of Punica granatum L. in the treatment of gingivitis: A review of ethnomedicinal uses, randomized clinical trials, and antibacterial potential against Porphyromonas gingivalis

ETHNOPHARMACOLOGICAL RELEVANCE

Mouthwashes based on medicinal plants have demonstrated benefits in controlling plaque and inflammation, acting positively on the oral hygiene of patients with gingivitis. In traditional medicine, Punica granatum L. has been used to treat oral diseases in countries in Europe, Asia, North America, and Africa.

AIM OF THE STUDY

The present study aimed to conduct a comprehensive review on the dental applications of Punica granatum L. for the treatment of gingivitis, including ethnomedicinal uses, analysis of randomized clinical trials, antibacterial activity against Porphyromonas gingivalis, mechanisms of action of phytochemicals isolated from this plant, and preclinical toxicity.

MATERIALS AND METHODS

The literature was retrieved from Google Scholar, PubMed®, SciELO, and ScienceDirect®, since the first report published on the topic in 2001 until March 2024.

RESULTS

Several clinical trials have demonstrated that mouthwashes containing P. granatum have equal or better efficacy than chlorhexidine in treating patients with gingivitis, confirming the indications for use of this plant by traditional communities. However, reports on the in vitro antibacterial activity of extracts from the fruits of this plant have not shown clinical relevance against the pathogen P. gingivalis. The ellagitannin punicalagin isolated from P. granatum has shown potential against several strains of Gram-positive and Gram-negative bacteria, but, to date, this compound has not yet been tested against P. gingivalis. It is likely that the mechanisms of action of flavonoids, such as quercetin, are involved in the inhibition of the activities of the RgpA, RgpB, and Kgp proteases of P. gingivalis.

CONCLUSIONS

In summary, natural products obtained from P. granatum do not present toxic side effects and can be considered as possible substitutes of commercial products recommended for the treatment of gingivitis and other oral diseases.

Clinical and Biochemical Efficacies of Green and White Tea Extract Mouthwashes in the Management of Plaque-Induced Gingivitis

OBJECTIVE

In this clinical study, chlorhexidine gluconate (CHX) was chosen as the positive control group, and the clinical and biochemical efficacy of mouthwashes with green tea, white tea and essential oil (EO) as the active ingredients were aimed to be examined comprehensively.

METHODS

A total of 112 participants with gingivitis were randomly assigned to four different groups and different mouthwashes were used for 4 weeks: CHX-MW group (as a positive control group), EO-MW group, GT-MW group and WT-MW group. The effects of the mouthwashes on plaque, inflammation and dental staining were evaluated by indexed scores at the beginning and 4th week. Markers related to gingival inflammation and oxidative stress were evaluated on samples from the gingival crevicular fluid.

RESULTS

In the 4th week, significant improvements in clinical parameters were found in all groups (p < 0.05) with the more pronounced improvement in the CHX-MW group (p < 0.05). However, only the CHX caused a significant discolouration of both teeth and tongue (p < 0.05). The levels of IL-1β and MMP-8 were found to be lower in all groups compared to the first measurements (p < 0.05). Furthermore, the antioxidant effect of EO mouthwash was found significantly low compared to the other three mouthwashes (p < 0.05).

CONCLUSION

Green and white tea extracts provided clinical benefits in the short term (1 month) with no statistical difference from each other and mouthwash with EO as the active ingredient while they provided a lower clinical benefit compared to CHX. Products with tea as the active ingredient may be an alternative to EO mouthwash for short-term and long-term use.

Comparison of the anti-plaque and anti-gingivitis efficacy of Chlorhexidine and Malva mouthwashes: Randomized crossover clinical trial

OBJECTIVES

Although mechanical oral hygiene is widely practiced, it faces several challenges. Mouthwashes, such as chlorhexidine (CHX), are being explored as adjuncts to biofilm control, but their prolonged use has several side effects. Consequently, there is ongoing research into natural alternatives. This randomized crossover clinical study aimed to compare the antiplaque and antigingivitis efficacy of 0.12 % CHX and a 5 % Malva sylvestris.

METHODS

Forty-four participants were involved in two phases, each comprising three stages with variations in the mouthwash solution used only. During the study, participants refrained from mechanical plaque removal for seven days. At first day, they received whole-mouth prophylaxis and oral health assessment. After three days, gingival inflammation assessment and prophylaxis in were performed in contralateral quadrants. Participants then used a randomly assigned mouthwash solution for four days. On the 7th day, they completed a questionnaire about their perception and appreciation of the mouthwash. Additionally, gingival inflammation and plaque index were also performed by a calibrated examiner. After a minimum 21-day washout period, participants entered the second phase, repeating the three stages.

RESULTS

Results showed no statistically significant differences between the Malva sylvestris and CHX groups regarding inflammation and plaque formation. However, CHX demonstrated a significantly greater mean reduction (7th - 4th day) in gingival inflammation compared to Malva (p = 0.02) (0.01 ± 0.19 and 0.00 ± 0.19, respectively). Additionally, participants using CHX reported a more pleasant taste and considered higher plaque control perception (p < 0.05).

CONCLUSIONS

In conclusion, both products exhibited similar antiplaque effects, but CHX outperformed Malva in controlling gingival inflammation.

CLINICAL SIGNIFICANCE

Mouthwashes with Malva sylvestris may be a good alternative, in a short-term period, to control biofilm. However, lower antigingivitis efficacy may be expected when compared to chlorhexidine.

Clinical efficacy of green tea, aloe vera and chlorhexidine mouthwashes in the treatment of dental biofilm induced gingivitis: A multi-arm, double-blinded, randomized controlled clinical trial

OBJECTIVE

This multi-arm, randomized, double-blinded, controlled clinical trial was designed to evaluate the clinical efficacy of 0.5% green tea (GT), 0.2% chlorhexidine (CHX) and aloe vera (AV) mouthwash as compared to the control (CNT) group (scaling and polishing alone with no mouthwash) in the management of dental biofilm induced gingivitis among 18-40-year-old patients.

MATERIAL AND METHODS

Sixty patients with generalized dental biofilm-induced gingivitis were randomly allocated to four study groups (n = 15 each) for treatment, namely Group GT, Group CHX, Group AV and Group CNT after scaling and polishing were administered to all the patients. Plaque index (PI), gingival index (GI) and sulcular bleeding index (SBI) were recorded at baseline, 14th and 21st day.

RESULTS

PI, GI and SBI at various time intervals (baseline, 14th and 21st day) showed high statistically significant differences within the group (p < 0.01). Among these, the maximum percentage change was found in the CHX group followed by GT when evaluated from baseline to 21st day. The least percentage change was found in the AV group for PI and GI while the CNT group showed the least percentage change for sulcular index when evaluated from 14th to 21st day. Inter-group results showed high statistically significant differences (p < 0.01) for PI and GI when evaluated between baseline to 14th day and baseline to 21st day. SBI also showed statistically significant differences (p < 0.05) when evaluated between baselines to 14th day and baseline to 21st day.

CONCLUSION

Green tea mouthwash displayed a significant reduction in plaque index, gingival index and sulcular bleeding index. 0.5% green tea catechin has equivalent anti-plaque efficacy as 0.2% chlorhexidine gluconate and can be considered a potent alternative to prevent and treat gingival diseases.

Comparative Evaluation of a Commercial Herbal Extract and 0.2% Chlorhexidine Mouthwash on Three Periodontal Facultative Anaerobes: An In Vitro Study

Background

The application of herbal and/or chemical antimicrobial mouthwashes in addition to the mechanical methods of bacteria removal helps reduce the periopathogens and thus increase the periodontal tissues' health. The present study aimed to evaluate the antibacterial effect of Thymex (TMX) syrup on three periodontal facultative anaerobes in vitro and compare it with 0.2% chlorhexidine (CHX) mouthwash.

Methods

In this in vitro experiment, the disc diffusion method was used to measure the inhibitory halo diameter (IhD) of Enterobacter cloacae, Actinomyces viscosus, and Eikenella corrodens. The paper discs containing TMX and CHX were placed on Mueller-Hinton agar media and cultured with the mentioned bacteria. Moreover, a blank disc containing distilled water was used as a control. From each of the three bacterial species, five samples were taken, and after 18 hours of storage in the incubator, the IhDs were measured in millimeters. A one-way ANOVA test and an independent sample t-test were used to compare the mean differences of IhDs between groups. The significance level was considered to be 0.05.

Results

The IhDs ranged between 6.2-8.8 mm and 12.3-34 mm for TMX and CHX, respectively. CHX showed a more inhibitory effect on all three species of bacteria compared to TMX mouthwash (P < 0.001).

Conclusions

Despite the inhibitory effect of TMX on bacterial growth, CHX showed significantly more antibacterial activity than TMX against three studied bacterial species.

Clinical Effectiveness of Herbal Oral Care Products in Periodontitis Patients: A Systematic Review

BACKGROUND

The use of herbal products in oral cavity has shown an increased popularity and potential benefits due to their additional anti-inflammatory and antioxidant properties as well as the lack of side effects related to their use.

OBJECTIVE

To assess the clinical effectiveness of herbal dental products (mouthwash, dentifrice, gel) when compared to conventional products or placebo in periodontitis patients.

MATERIAL AND METHODS

A systematic review with 22 studies was carried out using MEDLINE/Pubmed, EMBASE and Web of Science databases in addition to hand searches. Randomized and non-randomized clinical trials that evaluated the effect of any herbal dental product and compared it with conventional products or placebo in periodontitis patients and published up to March 2022, were screened.

RESULTS

Herbal products used as adjuncts to scaling and root planing (SRP) or supragingival debridement (SPD) led to superior clinical outcomes than placebo or no adjuncts (8 studies). In conjunction with SRP, these products showed comparable outcomes with chlorhexidine (6 studies) or better (4 studies). When used as adjuncts to SPD, herbal oral care products demonstrated comparable outcomes with chlorhexidine and conventional products (4 studies).

CONCLUSIONS

Within the limitations of this systematic review, herbal oral care products may play a key role in the management of periodontal disease. Further well-designed studies are needed to establish their efficacy.

The Effects of Curcumin in the Treatment of Gingivitis: A Systematic Review of Clinical Trials

Different modalities of treatments are available for management of gingival disease but most have adverse effects. Curcumin has anti-inflammatory properties and can be used for management of various inflammatory processes. This systematic review evaluates the effects of curcumin as an adjuvant to oral hygiene on plaque index (PI), gingival index (GI), gingival bleeding index (GBI), and inflammation in patients with gingivitis. A comprehensive search was conducted using PubMed/MEDLINE, Cochrane, SCOPUS, and Google Scholar. Based on the Population, Intervention, Control, and Outcome (PICO) model, clinical trials which tested the effects of curcumin as an adjunctive product or alone in control of gingival inflammation up until 21 February 2020 with language restrictions were selected. From the 422 papers found, 14 met the eligibility criteria. In most of these studies, curcumin treatment achieved significant reductions in PI, GI, GBI, and microbial colony count and was as effective as chlorhexidine mouthwash, with no serious adverse effects. We conclude that treatment with curcumin for gingivitis is safe as a natural herbal compound and is as effective as chlorhexidine mouthwash.