|Year : 2022 | Volume
| Issue : 1 | Page : 22-27
Comparative evaluation of antiplaque and antigingivitis effect of 3% Murraya koenigii mouthwash versus 0.2% chlorhexidine mouthwash: A randomized double-blinded controlled trial
Vartika Verma1, Shivani Sharma1, Sanjeev Kumar Salaria1, Sumit Malhotra2, Mohd Nazar Rana3, Pooja Mishra1
1 Department of Periodontics, Kalka Dental College, Meerut, Uttar Pradesh, India
2 Department of Periodontics, ITS Dental College, Ghaziabad, Uttar Pradesh, India
3 Department of Periodontics, Subharti Dental College and Hospital, Meerut, Uttar Pradesh, India
|Date of Submission||21-May-2021|
|Date of Decision||28-Jun-2021|
|Date of Acceptance||05-Jul-2021|
|Date of Web Publication||04-Jan-2022|
Department of Periodontics, Kalka Dental College, NH-58, Partapur Bye-Pass, Meerut - 250 006, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Introduction: Control of supragingival plaque has been the mainstay in the primary and secondary prevention of periodontal diseases. Due to the difficulty in achieving adequate plaque control by mechanical means, there is a great interest in the use of antimicrobial agents to replace or to be used as adjuncts to mechanical approaches. Herbal products are considered as an interesting alternative to synthetic antimicrobials due to their distinctive advantages. Murraya koenigii is one such herb which not only adds aroma to our food but also has a huge panorama of antimicrobial, antioxidative, and cytotoxic properties.
Aim: The aim of the study is to comparatively evaluate the effectiveness of 3% M. koenigii and 0.2% chlorhexidine gluconate (CHX) mouthwash in the reduction of plaque and gingivitis in patients suffering from mild to moderate gingivitis.
Materials and Methods: Forty-five participants participating in this study were divided into three groups and underwent Phase I therapy on the first visit. Patients were recalled after 7 days; Group M, Group C, and Group P participants were instructed to use 3% M. koenigii, 0.2% CHX, and placebo mouthwash respectively, twice a day, for a minute for 2 weeks as an adjunct to mechanical plaque control. Turesky–Glickman–Gilmore modification of Quigley Hein plaque index (PI) and modified gingival index (GI) were recorded at baseline (7th day) and at the end of the study (22nd day). Student's paired t-test and one-way analysis of variance test, post hoc analysis were used for intra and intergroup comparison of parameters, respectively.
Results: The results of the study showed that all the Groups M, C, P showed a statistically significant difference in gingival scores with a mean difference of 0.438 ± 0.234, 0.408 ± 0.388, 0.425 ± 0.237, respectively, when compared with baseline. Plaque scores for Group M and Group C were statistically significant with mean difference of 0.878 ± 0.433 and 1.090 ± 0.613, respectively. However, the mean change in PI and GI scores between the Groups M, P, and K was statistically nonsignificant.
Conclusion: M. koenigii mouthwash is equally effective as CHX, in the reduction of plaque and gingivitis.
Keywords: Chlorhexidine gluconate, gingival index, Murraya koenigii, plaque index
|How to cite this article:|
Verma V, Sharma S, Salaria SK, Malhotra S, Rana MN, Mishra P. Comparative evaluation of antiplaque and antigingivitis effect of 3% Murraya koenigii mouthwash versus 0.2% chlorhexidine mouthwash: A randomized double-blinded controlled trial. J Oral Res Rev 2022;14:22-7
|How to cite this URL:|
Verma V, Sharma S, Salaria SK, Malhotra S, Rana MN, Mishra P. Comparative evaluation of antiplaque and antigingivitis effect of 3% Murraya koenigii mouthwash versus 0.2% chlorhexidine mouthwash: A randomized double-blinded controlled trial. J Oral Res Rev [serial online] 2022 [cited 2022 Jan 28];14:22-7. Available from: https://www.jorr.org/text.asp?2022/14/1/22/334827
| Introduction|| |
Plaque is a known initiating factor in the development of gingivitis, and thus, plaque control represents the corner stone of good oral hygiene practice. There are physical and chemical approaches for controlling the plaque, where former is more common and cost effective, but because of its dependence to individual's hand skills, it cannot be reliable all the time, so the complimentary use of chemical methods has been demonstrated to meet adequate plaque control. Antimicrobial mouth rinses serve as an adjunct to methods of mechanical plaque control. CHX is considered as a gold standard for its property of chemical substantivity and its clinical efficacy in chemical plaque control. It appears to be the most effective antimicrobial agent for the reduction of both plaque and gingivitis. However, its long-term use has been reported with altered taste sensation, staining of teeth, and development of resistant micro-organisms. Hence, there is a need to develop some innovative strategies that act against microorganisms involved in the causation of dental caries and periodontal diseases. One such strategy would be to explore medicinal plants available abundantly in nature.
Natural herbs can be used exclusively or in combination and are proven to be safe and effective in the management of various health problems such as halitosis, bleeding gums, mouth ulcers, and dental caries. These have a dual advantage of minimal side effects and being alcohol and/or sugar free (as these are the two most common ingredients of the other over-the-counter products). Murraya koenigii, or curry-leaf, is native of India, Sri Lanka, and other South Asian countries and is distinguished by its sharp smell. It shows antimicrobial, antiemetic, antidiabetic, antiulcer, antioxidative, cytotoxic, and phagocytic activity. Chlorophyll content of curry leaf has been reported to be an anticariogenic agent and also helps in the reduction of halitosis. A randomized controlled trial has suggested M. koenigii mouthwash to be equally effective as chlorhexidine (CHX) mouthwash in treating plaque-induced gingivitis. As this previously reported study is the only study comparing CHX with M. koenigii. To strengthen/contradict the findings of previous research, the present study was undertaken to evaluate the clinical efficacy of M. koenigii as a mouthwash in the reduction of plaque and gingivitis. Thus, the objective of this short-term study was to evaluate the effectiveness of 3% M. koenigii mouthwash in comparison to 0.2% CHX mouthwash in the reduction of plaque and gingivitis.
| Materials And Methods|| |
For this double-blinded randomized controlled clinical trial a total of 56 individuals [Figure 5], who reported to the Outpatient Department of Periodontology and Oral Implantology, were examined for eligibility, 51 fulfilled the inclusion criteria and a total of 45 participants within the age group of 20–45 years were selected on the basis (α: 0.05, power: 90%, β: 0.1, CI: 80%, coefficient of variation percentage: 17.5, n: 14), and considering the unknown error, the sample size was increased to 15). Thus, 15 participants were allocated in each group using a lottery method. These patients were randomly divided into three study groups by an independent examiner. Group M: individuals were prescribed 3% M. koenigii mouthwash, Group C: 0.2% CHX mouthwash, and Group P: A placebo mouthwash for 2 weeks respectively. Both the participants and the examiner assessing the parameters were blinded to the type of mouth wash allocated in the study. The study was carried out in accordance with the ethical standard outlines in 1964, Declaration of Helsinki as revised in 2008 and was approved by Institutional Ethical Committee, and informed consent was taken from all the patients participating in the study.
|Figure 5: Consort Flow Chart describing the study population, (n= number of sample)|
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The inclusion criteria included participants within the age group of 20–45 years, minimum of 20 teeth, mild-to-moderate gingivitis with modified gingival index (GI), and plaque index (PI) scores <3. Smokers, alcoholics, pregnant or lactating females, participants using nonsteroidal anti-inflammatory drugs, on antibiotics in the past 3 months, those who underwent scaling in the past 6 months or with prosthetic or orthodontic appliances, allergy to active ingredients, and those who did not sign the informed consent were excluded from the study.
The minimum inhibitory concentration (MIC) of ethanolic extracts of M. koenigii for this study was estimated as 0.8 mg/ml based on an in vitro study conducted by Nithya et al., against the most predominant periodontal pathogens such as Porphyromonas gingivalis and Prevotella intermedia. Preparation of M. koenigii mouthwash was in accordance to the method elaborated by Nithya et al. and was carried out at College of Pharmacy. The fresh curry leaves [Figure 1] were dried under the sun for 3–4 days and thereafter crushed to obtain fine powder [Figure 2]. A total of 135 g of powder were mixed in 4500 ml of distilled water to make the concentration of solution as 3%. The solution was dispensed in conical flasks [Figure 3] and kept in rotary shaker [Figure 4] at 120 revolutions per minute for 18 h and then filtered. To improve patient compliance, 10 mL of glycerine (sweetening agent) and 5 mL of Pudin Hara (flavoring agent) were added. All the three mouth washes were dispensed in opaque bottles and were sequentially numbered.
Three appointments were scheduled for each individual who was the part of the study. Scaling and root planing were done on the first visit. On the 7th day (baseline), the patients were recalled for the recording of indices and were instructed to use mouthwash, which was randomly assigned to them. Individuals were instructed to the use 10 ml of mouthwash twice daily for 1, 30 min after brushing and were instructed not to drink or eat anything for 30 min after using the prescribed mouthwashes. Participants were then recalled on the 22nd day for recording of indices at the end of the study.
The PI and modified GI were recorded at baseline and on the 22nd day of postprescribed mouthwash usage by the examiner who was blinded toward the allocation of participants. The data collected was entered in Microsoft Excel, and statistical analyses were performed using SPSS version 23 software (Statistical Product and Service Solutions, IBM SPSS Statistics). Post hoc analysis, one-way analysis of variance (ANOVA), and student's t-test were used to test the intergroup and intragroup comparison between the groups, and P ≤ 0.05 was considered as statistically significant.
| Results|| |
All the participants completed the study and the mean age for Group M, Group C, and Group P was 31.2, 30.5, and 26.6 years, respectively. Intragroup comparison (paired t-test) of plaque scores for Group M and Group C at baseline and on the 22nd day was reported to be statistically significant with P = 0.003 and P = 0.002, respectively. For Group P, the plaque scores were statistically nonsignificant, with P = 0.33 [Table 1]. Intergroup comparison (one-way ANOVA test) of mean change in PI scores between baseline and on 22nd day for Groups M, C, and P was 0.878 ± 0.433, 0.331 ± 0.844, and 1.090 ± 0.613, respectively (P = 0.378) which was reported to be statistically nonsignificant [Table 1]. On post hoc analysis, the mean difference in scores between the groups at different time intervals, Group M versus Group P: 68.54 (P = 0.22), Group M versus Group C: 0.71 (P = 0.99), Group P versus Group C: −67.83 (P = 0.23) was also reported as statistically nonsignificant [Table 2].
|Table 1: Comparison of change in PI (Plaque Index) & GI (Gingival Index) Scores at Baseline and 22nd Day|
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On intragroup comparison, the GI scores for Group M, Group P, and Group C at baseline and on the 22nd day were reported to be statistically significant with P = 0.003, P = 0.032, P = 0.003, respectively [Table 1]. Intergroup comparison of mean change in GI scores between baseline and on the 22nd day for Groups M, P, and K; 0.43 ± 0.23, 0.40 ± 0.38, 0.42 ± 0.23, (P = 0.162) was reported as statistically nonsignificant [Table 1]. The mean difference in scores between the groups, Group M versus Group P: 32.27, P = 0.103, Group M versus Group C: −0.090, P = 0.962, Group P versus Group C: −33.17, P = 0.095 was also statistically nonsignificant [Table 2].
| Discussion|| |
The present randomized double-blinded clinical trial was designed to evaluate the effectiveness of M. koenigii mouthwash in the reduction of plaque and gingivitis and to compare it with CHX. In the study, both M. koenigii and CHX exhibited statistically significant results in inhibiting gingival inflammation on the 22nd day. On intragroup comparison of clinical parameters, both Groups M and C showed a statistically significant reduction of mean plaque scores on the 22nd day. Furthermore, when GI scores were measured, all the three groups, Groups M, P, and C, showed statistically significant reduction on the 22nd day. The results in our study could be due to scaling at baseline for Group P, additional antimicrobial effects of M. koenigii against predominant periodontal pathogens and plaque inhibition property of CHX in preventing inflammation of the gums for Group M and Group C, respectively.
The reduction in GI and PI scores in our study was nonsignificant on comparing Group M versus Group P, Group P versus Group C, and Group M versus Group C. This denotes comparable efficacy of M. koenigii and CHX with adjunctive effects to mechanical means in inhibiting gingival inflammation. These results were in accordance with the study of Varghese et al. who showed that mean reduction in GI and PI was statistically significant on the 22nd day for all the three groups. Furthermore, no significant difference was seen when comparing M. koenigii with CHX, though the difference was significant when comparing with placebo. This was in contrast to our study, as no significant difference was seen when comparing Groups M and C with Group P, this could be attributed to the “Hawthorne effect” shown by the placebo group in our study.
The commercially available CHX is considered as one of the most effective antiplaque agents in dentistry. However, M. koenigii is an extremely popular ingredient of Indian cuisine and gives flavor and aroma to most of the recipes. The fresh curry leaves have broad antimicrobial effects on Streptococcus species as they contain 2.6% volatile essential oils such as sesquiterpenes and monoterpenes, which are soluble in water. Series of substituted carbazoles, N-alkylated 3,6-dihalogenocarbazoles, present in M. koenigii, exhibit fungicidal activity against Candida albicans. The major component responsible for aroma and flavor has been reported as caryophyllene, cadinol and cadinene, pinene, and sabinene. Chowdhury et al. reported that alkaloids present in the curry leaf have antimicrobial activity against Gram-positive and Gram-negative bacteria and fungi. According to Math and Balasubramaniam, chewing 2–4 fresh curry leaves with 10–15 ml water, swishing for 5–7 min, and then, rinsing the mouth with water are very helpful in maintaining good oral hygiene.
MIC for M. koenigii in our study, i.e., 0.8% was based on the in vitro study conducted by Nithya et al. and was in contrast to an in vitro study conducted by Chandrashekhar et al. who showed that polyherbal combination containing M. koenigii as one of the components has MIC which varies from 0.05%–0.25%, against Streptococcus mutans, Streptococcus sanguis, Streptococcus salivarius, Lactobacillus acidophilus, Fusobacterium nucleatum, and P. gingivalis. This difference in our study could be due to sole use of M. koenigii in comparison to the additive effect of polyherbal combination used in the other study.
In the present study, 0.2% concentration of CHX mouthwash was used based on studies of other authors. Neto et al. stated that there is no difference in the efficacy of CHX 0.12%–0.2%. Ernst et al. compared the effects of 0.2% and 0.12% CHX mouthwash on dental plaque and gingival inflammation and concluded that the increase in the concentration of CHX provided no clinical advantages or disadvantages. Keijser et al. evaluated inhibition of plaque growth using 0.12% and 0.2% CHX and found no statistical difference with respect to plaque accumulation.
However, the smaller sample size and the lack of microbiological confirmation of the findings can be considered as study limitations. As it was a short-term study, further long-term trials using mouthwash for longer duration with large sample size are necessary to validate our result.
| Conclusion|| |
In the present study, M. koenigii mouthwash was found to be as good as an alternative to CHX which has side effects when used on long term in preventing the development of plaque and gingivitis. It can be easily recommended, as herbal products are easily available, cost effective, socially acceptable with no or minimal side effects, thus, opening a new herbal era for the maintenance of oral health.
We would like to acknowledge, Management, Kalka Group of Institutions, Meerut, for their constant support, in providing us the infrastructure and basic amenities to conduct this work.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
The study was conducted after approval from the Institutional Ethical Committee.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
[Table 1], [Table 2]