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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 12  |  Issue : 2  |  Page : 76-81

Pragmatic effect of an essential oil mouthwash as an adjunct to scaling on bacterial growth and gingival inflammation: A randomized controlled study


Department of Periodontics, Panineeya Institute of Dental Sciences and Research Center, Hyderabad, Telangana, India

Date of Submission04-Nov-2019
Date of Decision16-Jan-2020
Date of Acceptance19-May-2020
Date of Web Publication22-Jul-2020

Correspondence Address:
Jammula Surya Prasanna
Department of Periodontics, Panineeya Institute of Dental Sciences and Research Center, Road No-5, Kamala Nagar, Dilsukh Nagar, Hyderabad - 500 060, Telangana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jorr.jorr_39_19

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  Abstract 


Background: Dental plaque, comprehend of microorganisms which are considered as a main etiological factor for gingivitis, is the mildest form of periodontal diseases. This burden can be reduced by scaling, but additive effects can be achieved using mouthwashes as an adjunct.
Aims: To assess the clinical efficacy of essential oil (EO) mouthwash containing a combination of peppermint oil and tea tree oil on the reduction of bacterial plaque, gingivitis, as well as the colony forming units (CFU) before and after scaling.
Materials and Methods: This double-blind randomized clinical trial contains thirty subjects with severe gingivitis. All were divided into three groups, A, B and C, each group contains ten patients. Baseline plaque samples were collected for microbiological evaluation from all the subjects, and plaque index (PI) and gingival index (GI) were recorded. Patients in Group A have been prescribed 10 ml of freshly prepared mouthwash after scaling thrice a day for 3 weeks; patients in Group B underwent scaling only. Patients in Group C have been prescribed only 10 ml of mouthwash without scaling. After 3 weeks, plaque samples were collected to reevaluate PI, GI, and CFU from all the samples.
Statistical Analysis: One-way analysis of variance and paired sample t-test were used for analysis.
Results: Reduction was seen in PI, GI and CFU in Groups A and B when compared to Group C, and there was also a significant reduction seen in Group A when compared to Group B, when P < 0.05 was considered significant.
Conclusions: EO mouthwash was effective in the treatment of plaque-induced gingivitis as an adjunct to scaling without any side effects.

Keywords: Gingivitis, mouthwash, oral health, plaque control, plaque


How to cite this article:
Madhavi B, Prasanna JS. Pragmatic effect of an essential oil mouthwash as an adjunct to scaling on bacterial growth and gingival inflammation: A randomized controlled study. J Oral Res Rev 2020;12:76-81

How to cite this URL:
Madhavi B, Prasanna JS. Pragmatic effect of an essential oil mouthwash as an adjunct to scaling on bacterial growth and gingival inflammation: A randomized controlled study. J Oral Res Rev [serial online] 2020 [cited 2020 Aug 13];12:76-81. Available from: http://www.jorr.org/text.asp?2020/12/2/76/290507




  Introduction Top


Periodontal diseases affect the supporting tissues of the teeth. Gingivitis, the mildest form of periodontal disease, is generally caused by improper oral hygiene.[1] Since 1900,[1] the main etiological factor for gingival and periodontal disease was considered as dental plaque. The quality of plaque deposition is directly proportional to the severity of gingivitis.[1] The most rational methodology toward the prevention of gingivitis or periodontal diseases would be regular, effective removal of plaque by the personal oral hygiene protocol. Gingivitis can be treated by scaling, but meticulous plaque control cannot be achieved by this alone. Plaque control methods include mechanical and chemical methods. Oral prophylaxis by professionals, tooth brushing, interproximal cleaning using dental floss, and/or interproximal brushes are the mechanical methods. Use of a dentifrice, mouthwash, etc., refers to chemical methods.[2] These antimicrobial chemical agents have been employed extensively as an adjunct to mechanical cleaning. Several antimicrobial chemical agents such as chlorhexidine and metronidazole have been used. However, with these artificial drugs, unpleasant side effects have been noticed; hence, researchers are trying to give more attention to herbal products.[3] Essential oils (EOs), also called volatile oils or aromatic oily aqueous materials that are obtained from different types, as well as different parts of plants, are generally considered as safe.

EOs such as tea tree oil (TTO), peppermint oil (PO), lavender oil, thyme oil, and eugenol oil have been conventionally used in different parts of the world by people for various purposes.[4] Using such herbal mouthwashes, we can overcome the adverse effects caused by chemical mouthwashes such as unwanted stains and burning sensation. The main advantage of using herbal mouthwashes is cost-effective and has very minimal side effects with major benefits. According to null hypothesis, there is no difference between pre- and post-treatment values of mouthwash on gingival index (GI), plaque index (PI), and colony forming units (CFU). Therefore, this present study aimed to evaluate the efficacy of herbal mouth wash alone and as well as in the combination of the scaling on the reduction of bacterial plaque, gingivitis, and CFU.


  Study Design Top


After approval of the institutional ethical committee (Protocol Ref No. 0015), a total of thirty subjects [Figure 1], aged 20–45 years were enrolled in this study from the outpatient department of periodontology, Hyderabad, who were recruited from January to March 2018. The study was completed in April 2018. The sample size was calculated by a 95% confidence interval; for 90% power of the study, the sample size was 12; and for 80% power, we needed a sample size of 10. The study design was explained to all the patients, and written consent was obtained from all the subjects before commencement of the study. Computerized allocations of groups were done randomly; the person who was performing the entire study and the patients were blinded.
Figure 1: Patient selection criteria

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Inclusion criteria

Healthy patients aged 20–45 years (no other systemic diseases and no other periodontal diseases diagnosed) diagnosed with severe gingivitis with a minimum of 20 teeth present in the dentition were included.

Exclusion criteria

Patients who had undergone any other dental treatments and on antibiotic therapy from the past 3 months including the day of sample collection were excluded. Patients with untreated caries, orthodontic or prosthodontic appliances, and other factors that favor plaque retention were excluded.

Mouthwash preparation

Ingredients

Prepared the mouthwash by adding commercially available essential oils TTO and PO to water. The ratio is:

  • 5 drops P O
  • 5 drops TTO
  • 2 cups of water (each cup equal to 60 ml).


With the above concentrations, 0.02%v/v mouthwash was freshly prepared and given to the patient which was refrigerated, and patients were advised to use for only 1 week due to the shelf life of these EOs. After 1 week, remaining was discarded and fresh preparation was given.

Clinical parameters

PI (Silness and Loe),[5] GI (Loe and Silness),[5] and total CFU were evaluated for all the participants at baseline and after 3 weeks. CFU was evaluated by standard spread plate count method wherein 10 ml phosphate-buffered solution (PBS) with plaque samples was serially diluted as 10-1, 10-2, 10-3, 10-4, 10-5, and 10-6. From each dilution, a 0.1 ml sample was spread on nutrient agar plates. These plates were incubated at 37°C for 48 h, and the number of CFU was recorded after 48 h.


  Materials and Methods Top


Thirty subjects with severe gingivitis based on GI scores[5] were included in this study. They were randomly divided into three groups.

  • Group A (10 subjects): After sample collection, scaling was carried out in the same appointment. This group was prescribed EO mouthwash 10 ml thrice daily for 3 weeks. Oral hygiene instructions were given. Subjects were assessed again after 3 weeks
  • Group B (10 subjects): Scaling was carried out in the same appointment at baseline. This group was not prescribed any mouthwash. The assessment was done after 3 weeks
  • Group C (10 subjects): Scaling was not carried out in this group. Baseline only EO mouthwash 10 ml thrice daily for 3 weeks was prescribed. Oral hygiene instructions were given and were assessed again after 3 weeks. Without mechanical therapy how effective this mouthwash was tested in this group.


Patients were strictly instructed not to use any other mouthwashes during the study period and asked to brush twice daily with prescribed toothpaste and brushing techniques.

The primary outcome measured was a reduction in the CFU, and the secondary outcome measured was the effect of mouthwash on plaque scores and gingival bleeding.

Data were analyzed using SPSS Version 23 (Armonk, NY: IBM Corp). The descriptive, paired t-test was done for values obtained at various intervals. Statistical mean differences among the groups were calculated using analysis of variance. P < 0.05 was set as significant. There was a statically significant reduction observed (P < 0.001) among all the groups (PI, GI, and CFU) from baseline to 3 weeks of posttreatment [Table 1].
Table 1: Comparison of clinical parameters in all the three groups

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  Results Top


After 3 weeks in Group A, significant reduction was seen in both PI (2.18 ± 0.1–0.69 ± 0.2) and GI (2.28 ± 0.1–0.7 ± 0.4) followed by Group B PI (2.21 ± 0.1–1.06 ± 0.2) and GI (2.29 ± 0.1–1.2 ± 0.4) [Table 1] and [Graph 1] and [Graph 2]. CFU after 3 weeks, significant reduction was seen in Group A (227.4 ± 22.3–95.8 ± 18.1 CFU/ml) [Figure 2] followed by Group B (227.1 ± 16.2–183.9 ± 11.1 CFU/ml) [Figure 3], [Table 1], and Graph 3]. Group C had shown no significant reduction in PI (2.26 ± 0.1–2.27 ± 0.1) and GI (2.29 ± 0.1–2.32 ± 0.1), but slight reduction was seen in CFU (218.1 ± 13.1–207.5 ± 37.4) [Figure 4] and [Table 1].
Figure 2: Colony forming units in Group A at baseline and 3 weeks

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Figure 3: Colony forming units in Group B at baseline and 3 weeks

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Figure 4: Colony forming units in Group C at baseline and 3 weeks

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  Discussion Top


Dental plaque is the main etiological factor that is considered to aggravate gingivitis and further leads to periodontitis. Prevention of this type of disease is only possible through meticulous plaque control methods, such as mechanical as well as chemical methods.[1] However, it has been revealed that the majority of patients will not always completely remove the plaque in these ways. Furthermore, for handicapped or elderly individuals, use of mechanical plaque control methods is more challenging due to their compromised dexterity or lack of motivation. To overcome these shortcomings, antimicrobial rinses have been used as an adjunct to mechanical methods in reducing plaque-induced gingivitis.[2] In spite of potent antimicrobial and antiplaque properties of commercially available mouthrinses, its widespread and prolonged use is limited by its local side effects. In view of this, herbal products are steadily gaining interest in the present era as they are naturally occurring as well as economical. They also claim to have little or no side effects. Herbal mouthrinse has shown an antibacterial and anti-inflammatory effect in a few studies.[6],[7],[8] Therefore, the present study was carried out to evaluate whether the clinical and antimicrobial efficacy of EO mouthrinse which is a combination of PO and TTO as an addendum to scaling.

The main distinguishing feature of EOs and their components is hydrophobicity, which facilitates to pull apart with the lipids present in the cell membrane of bacteria and mitochondria, rendering them more permeable by disturbing the cell structures. This eventually results in the death of a bacterial cell due to leakage of critical molecules and ions from the bacterial cell to a great extent.[4],[9]

Tea tree (Melaleuca alternifolia) belongs to the family of Myrtaceae; the main constituent of its oil is terpinen-4-ol, an alcoholic terpene with a clean musty aroma. Antibacterial, anti-inflammatory, antiviral, insecticidal, and immune-stimulant are the main properties of tea tree.[10] Antimicrobial activity of TTO is due to terpinen-4-ol, α-terpineol, and 1, 8-, which cause leakage of 260-nm light-absorbing materials and render cells susceptible to sodium chloride. Thus, TTO causes lysis and the loss of membrane integrity and function manifested by the leakage of ions and the inhibition of respiration.[3] Conclusively, it was observed that among 15 genera of oral bacteria, 161 isolates were sensitive to TTO.[11],[12],[13],[14],[15] The topical applications of 100% TTO is able to reduce the inflammation induced by histamine diphosphate after a period of 10 min. Existing data on various EOs show that noncytotoxic concentrations exert an anti-inflammatory action by increasing interleukin-10 production.[10]

Peppermint (Mentha piperita Linn.) belongs to the family of Lamiaceae. Menthol, a primary constituent of PO, entire pharmacological action, depends on this. PO is studied and documented for its anti-inflammatory, analgesic, anti-infectious, antimicrobial, antiseptic, antispasmodic, astringent, digestive, carminative, fungicidal effects, nervine stimulant, vasoconstrictor, decongestant, and stomachic properties.[10],[16]

The antimicrobial activities evaluated against common oral pathogens (Staphylococcus aureus, Enterococcus faecalis, Escherichia coli, and Candida albicans).[4],[8],[9],[12],[14],[15],[16] PO makes the mouth feel fresh and, of course, makes the formula taste good. PO can also help prevent halitosis by increasing salivation.[3]

Although some authors[17],[18] described some adverse effects such as allergy in relation to TTO, throughout the study period, no adverse effects were seen in our study. Only TTO extensively used in many studies in different forms; however, until now combination with PO was not done, according to authors' knowledge, this study is the first study using a combination of TTO and PO as a mouthwash.

In the present study, it was found that the mean value of PI, GI, and CFU has decreased in Groups A and B from baseline to 3 weeks. Intergroup comparison revealed that there was a statistically significant reduction seen in Group A than Group B. There was no significant reduction in Group C from baseline to 3 weeks.

The significant reduction in Group A could be due to the antimicrobial activity of PO and TTO.

These study results were in accordance with the study done by Thosar et al.[3] in their study also essential oil used as an intracanal antiseptic solution, and they found a significant inhibitory effect on oral pathogens.[3]

These study results are also in accordance with the study done by Soukoulis and Hirsch.[11] They have tried TTO gel and reported that gingival inflammation reduced compared to other gels. However, the same study is partially contradicting our study as they proposed that plaque inhibition was not significant.

Rahman et al.[19] in their study used TTO as a mouthwash; they concluded that the reduction of plaque scores was significant; these study results are in accordance with our study. The results of the studies by Aspalli[1] and Prasad et al.[20] are in accordance with our study results; they have concluded that plaque-induced gingivitis effectually treated with herbal mouthwashes as an accomplice to mechanical therapy. Many authors[21],[22],[23],[24] have tried other herbal products as a single or combination of other products, and some used in combination with some chemical products. However, the results showed mixed views; no concluding results pertaining to EOs as well as other herbal products were made. However, in our study, we can firmly conclude that using the combination of EO mouthwash as an adjunct to scaling reduced the plaque scores, gingival bleeding, as well as oral bacterial count; however, we could not assess the nature of bacteria. Limitations of this study are a small sample size since this is an initial study. The shelf life of the products used was very short, so evaluation was done for a shorter period. Specific periodontal pathogenic bacteria were undiagnosed.


  Conclusion Top


From the present study, it concluded that EO mouthwash was effective in the treatment of plaque-induced gingivitis and effectively used as an adjunct to mechanical therapy with lesser side effects. Future studies related to such mouthwashes performed with a larger sample size with the aim to find their action on specific oral bacteria, which might prove to be very effective to promote oral health to all economically. Granted that, herbal products are as effective as chemical products; thus, the global burden of chemical usage will reduce.

Acknowledgment

Thanks to the Microbiology Department for Microbiological Analysis. Thanks to Alice Rani.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Aspalli S, Shetty VS, Devarathnamma MV, Nagappa G, Archana D, Parab P. Evaluation of antiplaque and antigingivitis effect of herbal mouthwash in treatment of plaque induced gingivitis: A randomized, clinical trial. J Indian Soc Periodontol 2014;18:48-52.  Back to cited text no. 1
[PUBMED]  [Full text]  
2.
Jafer M, Patil S, Hosmani J, Bhandi SH, Chalisserry EP, Anil S. Chemical plaque control strategies in the prevention of biofilm-associated oral diseases. J Contemp Dent Pract 2016;17:337-43.  Back to cited text no. 2
    
3.
Thosar N, Basak S, Bahadure RN, Rajurkar M. Antimicrobial efficacy of five essential oils against oral pathogens: Anin vitro study. Eur J Dent 2013;7:S071-7.  Back to cited text no. 3
    
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Chouhan S, Sharma K, Guleria S. Antimicrobial activity of some essential oils-present status and future perspectives. Medicines (Basel) 2017;4. pii: E58.  Back to cited text no. 4
    
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Fischman SL. Clinical index systems used to assess the efficacy of mouthrinses on plaque and gingivitis. J Clin Periodontol 1988;15:506-10.  Back to cited text no. 5
    
6.
Noumi E, Merghni A, Alreshidi M, Haddad O, Akmadar G, De Martino L, et al. Chromobacterium violaceum and Pseudomonas aeruginosa PAO1: Models for evaluating anti-quorum sensing activity of Melaleuca alternifolia essential oil and its main component terpinen-4-ol. Molecules 2018;23. pii: E2672.  Back to cited text no. 6
    
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Chatterjee A, Debnath K, Rao NK. A comparative evaluation of the efficacy of curcumin and chlorhexidine mouthrinses on clinical inflammatory parameters of gingivitis: A double-blinded randomized controlled clinical study. J Indian Soc Periodontol 2017;21:132-7.  Back to cited text no. 7
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Groppo FC, Ramacciato JC, Simões RP, Flório FM, Sartoratto A. Antimicrobial activity of garlic, tea tree oil, and chlorhexidine against oral microorganisms. Int Dent J 2002;52:433-7.  Back to cited text no. 8
    
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Sharifi-Rad J, Salehi B, Varoni EM, Sharopov F, Yousaf Z, Ayatollahi SA, et al. Plants of the Melaleuca genus as antimicrobial agents: From farm to pharmacy. Phytother Res 2017;31:1475-94.  Back to cited text no. 9
    
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Dagli N, Dagli R, Mahmoud RS, Baroudi K. Essential oils, their therapeutic properties, and implication in dentistry: A review. J Int Soc Prev Community Dent 2015;5:335-40.  Back to cited text no. 10
    
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Soukoulis S, Hirsch R. The effects of a tea tree oil-containing gel on plaque and chronic gingivitis. Aust Dent J 2004;49:78-83.  Back to cited text no. 11
    
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Arweiler NB, Donos N, Netuschil L, Reich E, Sculean A. Clinical and antibacterial effect of tea tree oil – A pilot study. Clin Oral Investig 2000;4:70-3.  Back to cited text no. 12
    
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Cox SD, Mann CM, Markham JL. Interactions between components of the essential oil of Melaleuca alternifolia. J Appl Microbiol 2001;91:492-7.  Back to cited text no. 13
    
14.
Papadopoulos CJ, Carson CF, Hammer KA, Riley TV. Susceptibility of pseudomonads to Melaleuca alternifolia (tea tree) oil and components. J Antimicrob Chemother 2006;58:449-51.  Back to cited text no. 14
    
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Comin VM, Lopes LQ, Quatrin PM, de Souza ME, Bonez PC, Pintos FG, et al. Influence of Melaleuca alternifolia oil nanoparticles on aspects of Pseudomonas aeruginosa biofilm. Microb Pathog 2016;93:120-5.  Back to cited text no. 15
    
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Sakkas H, Gousia P, Economou V, Sakkas V, Petsios S, Papadopoulou C.In vitro antimicrobial activity of five essential oils on multidrug resistant Gram-negative clinical isolates. J Intercult Ethnopharmacol 2016;5:212-8.  Back to cited text no. 16
    
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de Groot AC, Schmidt E. Tea tree oil: Contact allergy and chemical composition. Contact Dermatitis 2016;75:129-43.  Back to cited text no. 17
    
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de Groot A, Schmidt E. Essential oils, part V: Peppermint oil, lavender oil, and lemongrass oil. Dermatitis 2016;27:325-32.  Back to cited text no. 18
    
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Rahman B, Alkawas S, Al Zubaidi EA, Adel OI, Hawas N. Comparative antiplaque and antigingivitis effectiveness of tea tree oil mouthwash and a cetylpyridinium chloride mouthwash: A randomized controlled crossover study. Contemp Clin Dent 2014;5:466-70.  Back to cited text no. 19
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Prasad KA, John S, Deepika V, Dwijendra KS, Reddy BR, Chincholi S. Anti-plaque efficacy of herbal and 0.2% chlorhexidine gluconate mouthwash: A comparative study. J Int Oral Health 2015;7:98-102.  Back to cited text no. 20
    
21.
Neely AL. Essential oil mouthwash (EOMW) may be equivalent to chlorhexidine (CHX) for long-term control of gingival inflammation but CHX appears to perform better than EOMW in plaque control. J Evid Based Dent Pract 2012;12:69-72.  Back to cited text no. 21
    
22.
Parwani SR, Parwani RN, Chitnis PJ, Dadlani HP, Prasad SV. Comparative evaluation of anti-plaque efficacy of herbal and 0.2% chlorhexidine gluconate mouthwash in a 4-day plaque re-growth study. J Indian Soc Periodontol 2013;17:72-7.  Back to cited text no. 22
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Albert-Kiszely A, Pjetursson BE, Salvi GE, Witt J, Hamilton A, Persson GR, et al. Comparison of the effects of cetylpyridinium chloride with an essential oil mouth rinse on dental plaque and gingivitis – A six-month randomized controlled clinical trial. J Clin Periodontol 2007;34:658-67.  Back to cited text no. 23
    
24.
Charles CH, Mostler KM, Bartels LL, Mankodi SM. Comparative antiplaque and antigingivitis effectiveness of a chlorhexidine and an essential oil mouthrinse: 6-month clinical trial. J Clin Periodontol 2004;31:878-84.  Back to cited text no. 24
    


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