Efficacy of a commercially available multi-herbal formulation in periodontal therapy.

OBJECTIVE: This prospective clinical trial was designed to evaluate the clinical effects of a commercially available powder (Periocare(®) Gum massage powder), containing various herbal medicaments, in the reduction of plaque and gingival inflammation in subjects diagnosed with gingivitis.
MATERIALS AND METHODS: Seventy-five subjects diagnosed with chronic generalized gingivitis were selected and randomly divided into the following three groups: Group I - Scaling + Periocare(®) Gum Massage powder, Group II - Periocare(®) Gum Massage powder alone, and Group III - Scaling only. Clinical evaluation was done at baseline, 2 weeks, 4 weeks, and 6 weeks using gingival index, plaque index, and microbiological culturing of plaque samples.
RESULTS: Periocare(®) Gum Massage (multi-herbal formulation) powder as an adjunct to mechanical therapy (scaling) showed significant clinical and microbiological improvement in the gingival index and plaque index scores as compared to other groups. Periocare(®) Gum Massage powder as a monotherapy did not prove to be effective for plaque control.
CONCLUSION: Periocare(®) Gum Massage may be a useful herbal formulation for chemical plaque control and improvement in plaque scores and gingival status.

RCT Entities:   Population Interventions Outcomes

INTRODUCTION

Studies conducted throughout the world have proved that the incidence and prevalence of periodontal disease is increasing, and bacterial plaque is the primary etiological factor for it.[12] Experimental gingivitis studies have proved the role of plaque in the etiology of periodontal infections and demonstrated the direct relationship between plaque levels and the development of human gingivitis.[12] The status of oral hygiene, therefore, has a direct bearing on gingival health. Based on these findings, major efforts in preventive periodontics have focused on the various methods of plaque control.[3] Mechanical plaque control methods, like scaling, is the first recommended step in the management of gingivitis and periodontitis and are an indispensable phase of periodontal therapy,[4] but there are factors such as accessibility or presence of plaque retentive areas that can limit the clinical and microbiological response. Therefore, in addition to mechanical plaque control measures, chemical plaque control measures have also been advocated that can be used as adjuncts to mechanical measures, which together can reduce plaque and associated gingivitis. Although a number of chemical plaque control agents have been suggested, there is still a need for an anti-plaque agent that can be used on a daily basis with minimal side effects.

Herbal formulations can provide an option for safe and long-term use.[5] Certain plants used in folk medicine serve as a source of therapeutic agent by having multi-potential effects in addition to their antimicrobial activity. Recently, studies have been carried out to find out the effectiveness of herbal extracts on established plaque and gingivitis, but the literature regarding this is very limited. Periocare® Gum Massage powder§ is one such poly-herbal formulation that can be used to treat gingival inflammation and reduce the microbial load. Periocare® Gum Massage powder consists of Cinnamon zeylanicum, Piper nigrum, Eugenia caryophyllata, Glycyrrhiza glabra, and Rubia cordifolia, all of which have been shown individually to exhibit antimicrobial and antiinflammatory properties.

Hence, the present study was undertaken as a prospective, randomized clinical trial to evaluate the efficacy of commercially available Periocare® Gum Massage powder, as a topical application and gum massage, in the reduction of plaque and gingival inflammation and in reduction of microbiological load in subjects with gingivitis.

MATERIALS AND METHODS

A total of 75 dentate subjects who reported to the Department of Periodontics, DAPM R V Dental College, Bangalore, were recruited for the study. Ethical clearance was obtained from the concerned Ethical committee of the institution. Subjects aged 20 to 40 years, having at least 20 teeth and with no history of periodontal therapy or previous use of antibiotics or anti-inflammatory medication within the preceding six months, were included in the study. Subjects with smoking habits, with known allergies to the constituents of the formulation, hematological disorders or other systemic illness, pregnant women, and women on oral contraceptives were excluded.

Each subject was randomly assigned to one of the three groups (25 subjects in each group): Group I - Scaling + Periocare® Gum Massage powder, Group II - Periocare® Gum Massage powder alone, and Group III - Scaling. In order to standardize the brushing technique, all the selected subjects were demonstrated the roll method of brushing technique and were educated and motivated to follow the same brushing technique during the course of the study. The powder was dispensed to subjects of Group I and II by a dental assistant not involved in the study. Subjects were instructed to apply a pea-sized amount of powder to the gums, twice daily, and to massage the gums gently by finger or soft brush an hour after regular brushing and to leave it for five minutes before rinsing. Subjects were also asked to refrain from all other unassigned forms of oral hygiene aids such as dental floss or oral rinse during the study. Subjects were assessed for gingivitis using the gingival index (GI) (Loe and Silness)[6], and for plaque using the plaque index (PI) (Tureskey et al. modification of Quigley Hein Index)[78] under identical conditions at baseline, 2 weeks, 4 weeks, and 6 weeks. In addition to clinical evaluation, sub-gingival plaque samples were taken with the help of sterile paper points and sent for microbiological examination to assess the colony forming units (CFUs).

All the selected subjects fulfilled the clinical criteria of gingival index scores between 1-2, plaque index scores between 1-2, probing pocket depth ≤3 mm, and with no attachment loss or radiographic evidence of bone loss.

Apart from clinical evaluation, subjective evaluation was also undertaken at each visit, using a questionnaire relating to the taste and flavor of the powder or any adverse effect experienced after use. To check for compliance, the participants were asked to return their assigned powder container, so that the investigator could verify the amount of powder that was used.

Collection of plaque sample

Sample sites were isolated using cotton rolls and supragingival plaque was removed to avoid sub-gingival plaque contamination. Sub-gingival plaque was collected using sterile absorbable paper points, which were inserted into gingival sulcus for 25 to 30 seconds and then transferred to preheated Robertson's cooked meat medium (2 ml) for culturing.

Microbiological procedure

Preheated Robertson cooked meat media and thioglycolate media were used to transport the paper points to the microbiological laboratory.

For aerobic culturing,[9] the trypticase soy agar plates were placed in an incubator and incubated at 37°C for 24 hours.

For anaerobic culturing,[9] anaerobic condition was achieved using a “Gaspak system.” Subculture from Robertson cooked meat media and thioglycolate media was done using trypticase agar plate. The system comprised a transparent plastic body jar£ with an air-tight lid fitted with a screened catalyst chamber containing palladium-sized aluminium pellets. Water was added to a disposable aluminium foil packet containing pellets of sodium borohydride, tartaric acid, and sodium bicarbonate. The packet was immediately put in the jar. Reactions then took place to supply hydrogen and carbon dioxide. The agar plates mounted on a metal stand were immediately placed in the jar and the lid was closed and clamped tightly. The jar was then placed in the incubator and incubated at 37°C for 48 hours. After the incubation period, the plates were observed for microbial growth. Using a colony counter, CFUs for each plate were counted.

Statistical analysis

Students paired ‘t’ test and unpaired ‘t’ test were used for statistical analysis. Paired ‘t’ test was used for intra-group comparison and unpaired ‘t’ test was used for inter-group comparison.

RESULTS

Mean plaque index and gingival index in all groups at different time intervals are shown in Table 1. Mean aerobic CFUs and anaerobic CFUs in all groups at different time intervals are shown in Table 2. There was no significant difference between Groups I, II, and III with respect to plaque index, gingival index, aerobic CFUs, and anaerobic CFUs at baseline. There was a gradual decrease in plaque index and gingival index scores by 2 weeks, 4 weeks, and 6 weeks of time interval, respectively, in all the three groups [Tables 1 and 2].

Table 1

Mean and standard deviation of plaque index and gingival index in groups I, II, and III at different time intervals

Table 2

Mean and standard deviation of aerobic and anaerobic colony forming units in groups I, II, and III at different time intervals

The results clearly demonstrated Scaling + Periocare® (group I) to be the most effective mode of treatment when compared to other groups. These findings are in agreement with a similar study by Sheshan et al.,[10] who found marked reductions in clinical parameters following the use of gumtone (a herbal product) as an adjunct to oral prophylaxis.

In subjects using Periocare® alone (group II), minor reductions were seen in clinical and microbial parameters. This may be attributed to the anti-inflammatory and antimicrobial effects of Periocare ingredients along with the mechanical use of the product on the gums which reduced the plaque index score and gingival index score to certain extent. The minor reduction obtained in clinical and microbiological parameters could be attributed to some amount of inflammation persisting due to the presence of sub-gingival plaque. In subjects treated by only Scaling (Group III), highly significant reduction was observed in clinical and microbiological parameters.

Inter-group comparison in various groups from base to 6th week showed a statistically highly significant reduction in Group I; significant reduction in Group II (Clinical and aerobic CFU), not significant in anaerobic CFU; and highly significant difference in Group III (Clinical and aerobic CFU) with significant reduction in anaerobic CFU [Table 3].

Table 3

Comparison of study parameters from base to 6th week

Inter-group comparisons between individual groups are tabulated in Table 4. Inter-group comparison between group I and group II showed that group I had very highly significant reduction (P < 0.001) in clinical parameters and microbial counts compared to group II. Similarly, inter-group comparison of group I and III showed highly significant reduction in clinical parameters and microbial counts in group I. Comparison of group II and III showed that group III had highly significant reduction in clinical parameters and microbial counts.

Table 4

Inter-group comparison between various groups

DISCUSSION

Plaque is the major etiological factor in gingival and periodontal disease and mechanical plaque control is undoubtedly the best approach for elimination of plaque. However, this procedure is tedious and it requires meticulous practice by the subject. Many chemotherapeutic agents have been introduced and widely studied, but most of them have side effects when used over a long time. Moreover, the increased awareness of environment and healthy lifestyle is generating some demand for more natural products such as those containing herbal extracts. In recent years, attempts have been made to test plants and plant products for their specific anti-plaque properties.

In this context, the present study evaluated the effectiveness of Periocare® gum massage powder in reducing plaque scores, gingival score, aerobic CFUs, and anaerobic CFUs. Periocare® gum massage is a brownish herbal preparation dispensed as a micro fine powder.

A total of 75 subjects were selected and divided into three groups. In group I, only scaling was done and then test product was given, in group II only test product was given, and in group III only scaling was done.

The best results in the present study were obtained when Scaling + Periocare® was used together. It showed a very highly significant reduction in clinical and microbial parameters. This can be attributed to the mechanical removal of microbial plaque by scaling procedure with the added benefits of anti-inflammatory, astringent, and antimicrobial actions exerted by Periocare® ingredients. In a similar study by Pradeep AR et al.,[11] the oral microbial load was found to be reduced after topical application of a herbal medicament containing mainly Acacia arabica. The results of our study also reported a reduction in the oral microbial flora in group I and group II subjects, which could be attributed to the antimicrobial action of various components of the test product used.

The positive effects of Periocare® gum massage powder can be attributed to its ingredients, such as C. zeylanicum, Piper nigrum, E. caryophyllata, G. glabra, and R. cordifolia.

Cinnamon zeylanicum (Ceylon cinnamon)

C. zeylanicum is known to have both antinociceptive and anti-inflammatory effects.[12] Quale JM et al. studied the in vitro activity of C. zeylanicum against fluconazole-resistant and susceptible Candida species. The results showed that three of the five subjects responded to C. zeylanicum.[13] Cinnamon extracts have also been reported to possess antioxidant properties.[14]

Piper nigrum (Piperaceae)

Pradeep CR et al. showed that piperine has an inhibitory action on nitric oxide production and TNF-α production,[15] both of which have a known role in the pathology of inflammation in periodontal disease. Another study reported that black pepper (Piperine) can be used as potential therapeutic tools to regulate inflammatory responses and prevent/attenuate carcinogenesis.[16] Piperine has also been shown to have anti-inflammatory properties.[17] More recently, Bae GS et al. showed that administration of piperine inhibited lipopolysaccharide (LPS)-induced inflammatory responses, leukocyte accumulation, and the production of tumor necrosis factor-alpha (TNF-alpha).[18]

Eugenia caryophyllata (Clove, Myrtaceae)

The methanolic extract of the cortex of E. caryophyllata (Myrtaceae) is reported to potently inhibit the prostaglandin E2 production in LPS-activated mouse macrophage. E. caryophyllata also suppressed the cyclooxygenase-2 (COX-2) gene expression in LPS-stimulated mouse macrophage cells.[19]

Glycyrrhiza glabra (Fabaceae, Liquorice, Jestimad)

Licorice (G. glabra) is an antiviral, expectorant, demulcent, anti-inflammatory, and immune stimulant.[20] G. glabra is also reported to have potent antibacterial action against a cariogenic bacterium S. mutans.[21] A recent systematic review by Amirghofran Z has discussed in detail the anti-inflammatory and immunomodulatory effects of G. glabra.[22]

Rubia cordifolia (Rubiaceae, Mamjisth)

Jain A et al. showed that R. cordifolia is effective against TNF-alpha.[23] It has also been reported to possess potent antioxidant properties[24] and nitric oxide-scavenging activity in vitro.[25]

All these herbal ingredients have been used for many centuries without any reported side effects. The results of this study suggest that Periocare® by itself cannot be a “stand alone therapy” in the prevention of plaque and gingivitis. When conventional mechanical plaque control methods were supplemented with Periocare® massaging, it resulted in very highly significant reduction in plaque scores, gingival scores, aerobic and anaerobic CFUs. In this study, oral prophylaxis (scaling) alone also resulted in significant reduction of all the measured variables; however, it is conceivable to suggest that Periocare® along with scaling is more beneficial in the treatment of periodontitis, which is primarily caused by anaerobic microorganisms.

Thus, from the present study, it can be concluded that mechanical plaque control coupled with multi-herbal formulation like Periocare® forms an effective method of plaque control and aid in maintaining optimum gingival health. The use of natural herbal preparations in healthcare continues to be popular and Periocare® powder may be a useful addition. Further long-term prospective studies are needed to confirm the results achieved in this short-term study.