Comparative Evaluation of Anti-Inflammatory Efficacy of Turmeric and Chlorhexidine Gel as an Adjunct to Scaling and Root Planing in the Treatment of Gingivitis.

BACKGROUND: Dental plaque is a complex ecosystem which consists of densely packed microbial colonies, microbial by-products, salivary glycoproteins and desquamated epithelial cells. Clinical studies have proved the relationship between plaque and periodontal disease. AIM: This study compares the anti-plaque efficacy and anti-inflammatory potential of turmeric gel with 0.2% chlorhexidine gel along with scaling and root planing (SRP).
MATERIALS AND METHODS: One hundred and fifty individuals were selected and divided into three groups for the study. Group A was instructed to use 0.2% chlorhexidine gel, whereas Group B used turmeric gel along with SRP. Participants were assessed for plaque and gingivitis on the 14th and 21st days. Subjective and objective criteria were assessed. The clinical data were recorded and used for statistical analysis to obtain results.
RESULTS: The percentage reduction of plaque index (PI) between the chlorhexidine and turmeric gel on 21st day were 74.85 and 65.91 respectively. similarly, the percentage reduction of gingival index (GI) between the chlorhexidine and turmeric gel on 21st day were 58.49 and 62.46 respectively.
CONCLUSION: Turmeric gel shows a slightly lower anti-plaque property in comparison to chlorhexidine gel. Their effect on a reduction of gingival inflammation was equal. It was also noted that turmeric gel showed better acceptability and biocompatibility by the participants. Copyright:

INTRODUCTION

Dental plaque is a complex ecosystem which consists of densely packed microbial colonies, microbial by-products, and glycoproteins desquamated epithelial cells. Dental plaque-induced gingivitis, if not treated, can advance to periodontitis with severe destruction of gingival tissues and bone tissues.[12] The main objective of periodontal therapy is to restore the oral health which can be achieved by reducing the levels and proportions of pathogenic bacteria in oral biofilms that produce metabolites causing gingivitis and periodontitis. The routine treatment procedure of gingivitis is scaling and root planing (SRP) which involves the removal of accumulated supragingival and subgingival plaque and calculus.[3]

Microbial assay of plaque-induced gingivitis shows that the proportion of Gram-positive species is around 56% and Gram-negative species is 44%. The facultative microorganism is approximately 59% and anaerobic microorganism is 41%. Predominant Gram-positive species include Actinomyces viscosus, Actinomyces naeslundii, Streptococcus sanguis, Streptococcus mitis, streptococcus intermedius, Streptococcus oralis, and Peptostreptococcus micros. The Gram-negative microorganisms are predominantly Capnocytophaga, Fusobacterium nucleatum, Campylobacter sp., Veillonella parvula, Haemophilus, and Prevotella intermedia.[4]

The current periodontal treatment is directed at disruption of biofilm which usually includes professional and home care mechanical methods. This is based on the association of microorganisms with periodontal diseases. A variety of oral antimicrobial agents are available. Chlorhexidine is the most common and the gold standard anti-plaque and anti-gingivitis agent.[2] It consists of cationic biguanide molecule. It is a broad-spectrum antiseptic having effectiveness against Gram-positive and Gram-negative bacteria, yeast, dermatophytes, and some lipophilic viruses.[2] However, these chemicals have several side effects, so the herbal or “natural” products have started to gain popularity which has been included in oral care products. Ayurvedic formulations to treat diseases including periodontal diseases have been tried since ancient times. Turmeric (Haldi) is one of the traditional ayurvedic medicine products. It has been known to possess antibacterial, antiseptic, anti-inflammatory, hepatoprotective, immunostimulant, antimutagenic, antioxidant, and antimicrobial properties.[5678]

Till date, fewer research has been conducted to treat plaque-induced gingivitis and periodontitis by natural product (turmeric gel) and its comparison with gold standard 0.2% chlorhexidine. The evidence pertaining to the effectiveness of herbal products in the prevention of plaque formation is less. Hence, the aim of this study was to compare the effects of turmeric gel with 2% chlorhexidine gel in the prevention of plaque formation and gingivitis.

MATERIALS AND METHODS

One hundred and fifty individuals for the present randomized controlled clinical trial were selected and were divided into three groups of 50 individuals in each on a random basis.

Group A – Participants who received SRP and advised to use chlorhexidine gel

Group B – Participants who received SRP and advised to use oral turmeric gel

Group C – Control group in which participants received SRP only.

The inclusion criteria were patients of age 15 years and more with moderate-to-severe gingivitis and patients having minimum 20 erupted teeth. Exclusion criteria included patients taken periodontal therapy in the past 3 months, those who used antibiotics/antiseptic mouthwash in the past 3 months, patients wearing prosthetic or orthodontic appliances, and those having any systemic diseases such as heart problem, renal disorder, and diabetes mellitus.

The participants were examined and diagnosed in a dental setup under chair light. The patients' history and clinical data were recorded in a preformed case pro forma. Plaque and gingival inflammation conditions of the participants were assessed by recording plaque index (PI) (Turesky–Gilmore–Glickman modification of the Quigley–Hein, 1970)[9] and gingival index (GI) (Loe and Silness, 1963)[10] to get participants at the baseline. After recording both the indices,[11] SRP was carried out. Oral hygiene maintenance instructions were given to the participants. Participants were recalled on the 14th and 21st days after SRP, and PI and GI were again recorded. Out of 150 participants, 135 patients with mild-to-severe gingivitis were included to be part of the study. The study was conducted in collaboration with the Department of Orthodontics of the institution. Both the test groups were advised to use their respective oral gel twice a day after brushing for 1 min. Participants from Group A after receiving SRP were instructed to use chlorhexidine gel for a period of 1 min twice daily: in the morning and at night after brushing. Participants in Group B after receiving SRP were instructed to use turmeric gel with the same instructions as Group A. Participants in Group C were given SRP treatment for gingivitis.

OBSERVATIONS AND RESULTS

Out of a total number of 150 participants for the study, 135 patients with moderate-to-severe gingivitis were selected and were divided into three groups randomly. Out of 135 patients, 78 were male and 57 were female. Majority of the study population belonged to 21 and 30 years of age. SPSS statistical software of IBM company 21.0 version (full version) version 21.0 was used for data analysis. P < 0.05 was considered with 95% confidence interval in the study. Chi-square test was used for the statistical comparisons of nonparametric data. The statistical significance of the three-group comparison was analyzed using an independent Student's t-test.

In Table 1, for Group A, the mean PI at baseline was 3.34 ± 0.36; on the 14th day, it was 1.76 ± 0.38; and on the 21st day, it was 0.84 ± 0.27. For Group B, the mean PI at baseline was 3.27 ± 0.44, and on the 14th and 21st days, it was 2.03 ± 0.45 and 1.18 ± 0.13, respectively. For Group C, the mean PI at baseline was 3.34 ± 0.48; on the 14th day, it was 3.46 ± 0.19; and on the 21st day, it was 3.51 ± 0.16. The mean value of PI is reducing in Group A and Group B from baseline to 14 and 21 days showing its efficacy, whereas the mean in Group C is almost the same and increasing.

Table 1

The mean values of plaque index

Type of oral gel	Mean±SD			Mean difference	SE
	PI (baseline)	PI (after 14 days)	PI (after 21 days)
Chlorhexidine (Group A)	3.34±0.36	1.76±0.40	0.84±0.31	0.38	0.07
Turmeric (Group B)	3.27±0.44	2.03±0.45	1.18±0.16	0.30	0.05
SRP (Group C)	3.34±0.48	3.46±0.19	3.51±0.16	0.09	0.12

SD: Standard deviation, SE: Standard error, SRP: Scaling and root planing, PI: Plaque index

Table 2 shows a comparison of percentage reduction of PI between the chlorhexidine and turmeric gel from 0 to 14th day were 50.32 and 39.49, respectively. The percentage reduction of PI between 0 and 21st days was 74.85 and 63.91, respectively. The difference between the two groups in percentage reduction of plaque has t = 7.48 on 0–14th day and 6.63 on 0–21st day. The P value was 0.0041 on 0–14th day and 0.0023 on 0–21st day, which was statistically significant (P < 0.001). There is a statistically significant difference between Groups A and B, and Group A had more the percentage reduction in PI, which means that chlorhexidine is better than turmeric in reducing plaque.

Table 2

Percentage reduction of plaque index

Groups	Percentage reduction
	0-14 days	0-21 days
Chlorhexidine Group A	50.32	74.85
Turmeric Group B	39.49	63.91
Difference between groups
T	7.48	6.63
P	0.0041 (significant)	0.0023 (significant)

Table 3 showed for group A, the mean GI at baseline was 1.80 ± 0.12; on the 14th day, it was 0.87 ± 0.12; and on the 21st day, it was 0.73 ± 0.52, whereas for Group B, the mean GI at baseline was 1.81 ± 0.13; on the 14th day, it was 2.03 ± 0.45; and on the 21st day, it was 1.18 ± 0.16. Intragroup observations for GI showed a significant reduction score from day 0 to 14th day and from day 0 to 21st day for both the groups. The mean GI is reducing in Groups A and B, whereas in Group C, it is increasing, showing that Group C is ineffective, but Groups A and B are effective in reducing GI.

Table 3

Gingival index

Type of mouthwash	Mean±SD			Mean difference	SE
	PI (baseline)	PI (after 14 days)	PI (after 21 days)
Chlorhexidine (Group A)	1.80±0.12	0.87±0.12	0.73±0.52	0.93	0.07
Turmeric (Group B)	1.81±0.13	2.03±0.45	1.18±0.16	0.91	0.05
SRP (Group C)	1.7±0.24	2.12±0.25	2.34±0.26	1.2	0.12

SD: Standard deviation, SE: Standard error, SRP: Scaling and root planing, PI: Plaque index

Table 4 shows that the percentage reduction in GI in Group A from baseline was 52.39 on 0–14th day and 58.49 on 0–21st day. Similarly, in Group B, it was 49.35 on 0–14th day and 62.46% 0–21st day. The percentage reduction is more with Group B than with Group A. The P value was 0.453 on 0–14th day and 0.321 on 0–21st day, and there is no significant difference means they both are effective.

Table 4

Percentage reduction of gingival index

Groups	Percentage reduction
	0-14 days	0-21 days
Group A (chlorhexidine)	52.39	58.49
Group B (turmeric)	49.35	62.46
Difference between groups
T	32.92	42.39
P	0.453 (NS)	0.321 (NS)

NS: Not significant

DISCUSSION

Plaque control has an important role in the prevention of gingival and periodontal disease as bacterial plaque is the main causative agent for gingivitis and periodontitis. The most rational approach to the prevention and control of periodontal disease is the effective plaque removal at regular intervals by personal oral hygiene measures. Various chemical plaque inhibitors have been tried along with mechanical means. However, most of them have certain side effects and also are expensive.[12]

Turmeric or curcumin exhibits anti-inflammatory properties by reducing the inflammatory mediator generation via arachidonic acid pathway. This leads to inflammatory edema reduction and decreased engorgement of blood vessels in connective tissue.[13] It also enhances wound healing by promoting migration of fibroblasts in the healing site and by causing fibrosis of connective tissue.[13]

In the present study, it was observed that PI reduced progressively in Group A (0.2% chlorhexidine), which was consistent with the findings of Leyes et al.[14] and Grundenmann et al.[15] who compared chlorhexidine with different anti-plaque chemical agents. Plaque scores in Group A also reduced every week from baseline to 21st day by 61.76%. Our results were consistent with a study conducted by Bhandari and Shankawalker.[16]

The comparison between the turmeric gel and chlorhexidine gel showed a percentage reduction of PI between 0 and 14th day were 39.49% and 50.32%, respectively. The percentage reduction of PI from 0 to 21st days was 63.91% and 74.85%, respectively. Chlorhexidine gel shows marginally better results in plaque reduction as compared to turmeric gel. The property of substantivity of chlorhexidine can be the reason for its superiority and its inhibitory action at different steps of plaque formation. The turmeric gel also showed anti-plaque effect but less effective compared to chlorhexidine.

Our results were similar to the results of research carried out by Hase et al.[17] who compared the anti-plaque effectiveness of 0.2% delmopinol hydrochloride with 0.2% chlorhexidine digluconate mouthwash and inferred that chlorhexidine mouthwash showed a greater plaque reduction.

There are evidences which showed that dental plaque is the causative factor for gingivitis. GI reduced in the chlorhexidine group, every week from baseline to 21st day (58.49%), which was consistent with the findings of various other studies.[181920] The reduction of gingival inflammation using chlorhexidine gluconate was observed to be significant. Gingival scores were reduced in the turmeric gel group from baseline to 14th day (49.35%), followed by reduction on the 21st day (62.46%), which was consistent with the findings of Bhandari and Shankwalkar.[15] The reduction of the mean GI of turmeric gel in our study may be because of its anti-inflammatory activity. This was also concluded by other literatures.[21222324]

The comparison of GI between chlorhexidine and turmeric gel showed percentage reduction between 0 and 14th day were 52.39 and 49.35 respectively. The same were 58.49 and 62.46 respectively between 0 and 21st day. T value was 8.91 which was statistically non significant. However, it was not statistically significant.

In all the above studies, the anti-inflammatory effect of turmeric was observed. In our study, the evaluation of anti-inflammatory action of turmeric using clinical parameters of PI and GI showed a significant reduction.

CONCLUSION

The conclusion can be derived from the results that turmeric gel shows anti-plaque property. However, it was not statistically significant as compared to chlorhexidine.

Both turmeric and chlorhexidine gels were found to be equally effective when their effect on gingival inflammation was evaluated. On comparing the subjective and objective criteria, turmeric gel showed better acceptability and biocompatibility by the participants.

It is necessary to conduct a long-duration study on a bigger sample size to evaluate the anti-plaque and anti-inflammatory efficacy of turmeric before advocating the use of turmeric gel. It is also important to study the substantivity and other properties of turmeric gel. The different concentrations of turmeric gel can also be evaluated for the anti-plaque efficacy.

This study also gives a conclusion that both turmeric gel and chlorhexidine gel can be used as an adjunct to mechanical methods of plaque control in the prevention of periodontitis and gingivitis.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.