Effect of 0.4% Triphala and 0.12% chlorhexidine mouthwash on dental plaque, gingival inflammation, and microbial growth in 14-15-year-old schoolchildren: A randomized controlled clinical trial.

CONTEXT: A strong correlation exists between plaque and dental caries and periodontal diseases. Ayurvedic drugs have been used since ancient times; oral rinses made from these are used in periodontal therapy. Triphala is one of these with wide spectrum of activity. AIMS: To assess and compare the effect of 0.4% Triphala and 0.12% chlorhexidine (CHX) mouthwash on dental plaque, gingival inflammation, and microbial count of Streptococcus mutans, Streptococcus sanguinis, and Lactobacilli from dental plaque sample of 14-15-year-old schoolchildren of Pune city during 90 days supervised use. SETTINGS AND
DESIGN: A randomized, controlled, double-blind, parallel-group clinical trial was conducted among 72 schoolchildren aged 14-15 years. SUBJECTS AND METHODS: Children were divided into two study groups: Group A with 0.4% Triphala mouthwash (n = 36) and Group B with 0.12% CHX mouthwash (n = 36). The plaque Index (Loe H [1967]), gingival index (Loe H and Silness J [1963]), and microbial analysis were recorded at baseline, 30 days, and 90 days interval. STATISTICAL ANALYSIS USED: Statistical analysis was done using unpaired t-test for group-wise comparison and one-way analysis of variance test, followed by Tukey's post hoc test for intragroup comparison. P < 0.05 was considered statistically significant.
RESULTS: The results showed that 0.4% Triphala and 0.12% CHX have similar inhibitory effect on plaque accumulation, gingivitis, and growth of S. mutans, S. sanguinis, and Lactobacilli.
CONCLUSION: Herbal mouthwash proved to be helpful in reducing plaque microbial counts, plaque, and gingival inflammation and opens new arenas in the field of herbal dentistry and chemical plaque control. Copyright:

INTRODUCTION

Oral health, now recognized as equally important in reference to general health, has become an integral part of the overall health and well-being of an individual. Dental caries and periodontal diseases are the two leading oral pathologies that remain widely prevalent and affect almost all inhabitants throughout the lifetime.[1] Dental plaque has been proven to be a paramount factor in initiation and progression of dental caries, gingivitis, and periodontal diseases.[2]

Gram-positive streptococcus strains form the major group of organisms during the first few hours of plaque formation.[3] Streptococcus sanguinis (S. sanguinis) are the primary colonizers in the human oral cavity, and its elevated levels in the oral cavity were correlated to a significant delay in the colonization of mutans Streptococci.[45] Streptococcus mutans (S. mutans) metabolizes sucrose in a peculiar way, producing dextran, thus promoting the firm adherence of the organisms to the tooth surface[3] along with coaggregation mediated by a protein on the surface of the Lactobacilli,[6] consequently contributing to the formation of bacterial plaque and subsequently resulting in gingival inflammation and localized decalcification of the enamel.[3]

The National Oral Health Survey and Fluoride Mapping 2003, India, reported that 72.5% of 12-year-old children and 75.4% of 15-year-old children had dental caries, whereas 55.4% of 12 year or higher age groups had gingivitis. Gingivitis usually begins in childhood and features a lifelong squeal; hence, primary care must begin early in life before the onset of the problem.[7]

The removal of plaque is of utmost importance to control dental caries and gingivitis that is commonly maintained by mechanical methods. However, in children, factors such as lack of manual dexterity and individual motivation and monitoring limit the effectiveness of toothbrushing, particularly at interproximal sites, and necessitate the use of chemotherapeutic agents such as a therapeutic mouthrinse as an adjunct to mechanical plaque control.[89] Currently, chlorhexidine (CHX), a potent antibacterial substance, is employed as a gold standard chemical plaque control agent.[10]

However, excessive use of these antimicrobial agents may result in the development of bacterial resistance and derangement of the oral and intestinal flora and may cause undesirable side effects such as vomiting, diarrhea, taste alterations, and tooth staining. Hence, the use of herbal mouthwash in the prevention and treatment of oral conditions has increased recently.[9]

“Triphala” is among the most commonly used formula in traditional ayurvedic medicine as it has antibacterial, antiseptic, and anti-inflammatory properties. The 20th shloka of Sushruta Samhita has stated that Triphala can be used as a mouthrinsing agent in dental ailments.[11]

There is a need to investigate a suitable alternative, like Triphala which is locally available, renewable, culturally accepted, affordable, and effective against the oral pathogenic microorganisms.[12]

Hence, this study was conducted with the aim to clinically assess and compare the effect of Triphala and commercially available CHX mouthwash on the dental plaque, gingival inflammation, and microbial counts of S. mutans, S. sanguinis, and Lactobacilli counts among 14–15-year-old schoolchildren after 90 days of supervised use.

SUBJECTS AND METHODS

A randomized, controlled, double-blind, parallel-group clinical trial was conducted among 14–15-year-old children from private schools in Pune city, India. The reporting of the study is in accordance to the Consolidated Standards of Reporting Trials guidelines [Figure 1]. The study protocol was approved by the Ethical Committee of the Institutional Review Board (SDCH/IEC/OUT/2013-14/77) and the trial is registered under Clinical Trials Registry of India, CTRI/2017/10/010155. Furthermore, the necessary permissions were obtained from the concerned school authorities.

Figure 1

Schematic representation of study design as per the Consolidated Standards of Reporting Trials (CONSORT) guidelines. n – no of study participants, M – male, F – female

Preparation of Triphala and chlorhexidine mouthwashes

The Triphala mouthwash was formulated and developed in a private laboratory using the water-based liquid extract of Triphala. The prepared extract was tested for microbial activity on three oral pathogens, namely, S. mutans ATCC 25175, S. sanguinis ATCC 10556, and Lactobacillus ATCC 4356 by agar well diffusion assay using swab technique,[13] after which a minimum inhibitory concentration and the minimum bactericidal concentration of 0.4% was determined by the broth dilution test.[131415]

CHX gluconate mouthwash (Proprietary name: Eludril, concentration: 0.12%) procured from the market was given to the pharmacy manufacturing center for dilution with equal amount of sterile water. Both mouthwashes were made of identical colors and were dispensed in 500 ml bottles for use. The bottles were coded by the pharmacists, and at the end of the study, the decoding was done.

Pilot study

The training and calibration of the examiner for recording the indices was done by a subject expert before the start of the study. Intraexaminer agreement was determined using the weighted kappa (k = 0.81). The method of plaque sample collection, storage, and transportation was standardized after discussion with a microbiologist.

Study population

Schoolchildren aged 14–15 years from four private schools in the southwest zone of Pune city who were willing to participate in the study after giving written informed assent and consent obtained from their parents were selected.

Sample size determination

Sample size determination was based on the expected minimum reduction in plaque scores in the controlled group, as observed in a previous study.[14] Sample size of 36 participants per group was determined using the formula n = 2[Zα(σ)/d] 2 and considering 10% sample attrition rate. Thus, a total of 72 participants were included in the study.

Sampling methodology

First stage (selection of schools)

As per the details obtained from the education officer, there are a total of 90 private schools in Pune city. Schools with easy accessibility were identified and approached. Four schools who gave the requisite permissions were selected by lottery method.

Second stage (selection of study participants)

As per the below-mentioned inclusion and exclusion criteria, the study participants from all the four schools were screened and a separate list of girls and boys for each of the four schools was prepared. Then, by systematic random sampling, 18 study participants from each school were selected such that there were equal number of girls (n = 9) and boys (n = 9) in each group.

Inclusion criteria

Study participants aged 14–15 years having at least 20 intact natural teeth with similar socioeconomic status and oral hygiene practices as well as fair plaque score (Loe H 1967)[15] and moderate gingivitis (Loe H and Silness J 1963)[16] at baseline were selected.

Exclusion criteria

Study participants with any systemic disorders, having history of hypersensitivity to any product used in the study using other mouthrinses, and under antimicrobial therapy at least 3 months before the study were excluded.

Random allocation of the two mouthwashes

The selected four schools were randomly allocated by lottery method by a person not involved in examination into two study groups such that two schools per group with 36 study participants in each group. The study participants received the products according to the specified code. The two study groups were:

Group A: 0.4% Triphala mouthwash (n = 36)

Group B: 0.12% CHX mouthwash (n = 36).

Materials used for the study

Recording indices: Mouth mirror, explorer, Williams graduated probe, tweezers, and chip syringe

Collection of plaque samples: Eppendorf vials, transport media, and vaccine carrier with freezing mixture

Microbial analysis: Mitis salivarius bacitracin agar, blood agar, and Man, Rogosa, Sharpe (MRS) agar.

Blinding

Study participants and the examiner were blinded regarding the medicament allotted to the two intervention groups as the codes were given by a person not involved in the examination (pharmacist). All the microbiological procedures were performed by the microbiologist, who was blinded with respect to the plaque samples of different groups during the entire course of the study.

Study tools

The data were collected using an investigator-administered pro forma and by clinical examinations using plaque index (PI) by Loe H[15] and gingival index given by Loe H and Silness J (1963).[16] The total colony count scores of the plaque microorganism such as S. mutans, S. sanguinis, and Lactobacilli were also recorded.

Study setting

Type III clinical examination, as recommended by the American Dental Association,[17] was conducted in a chair/school bench, in the selected four schools.

Collection of plaque samples and microbial analysis

The study participants were made to sit on a chair and the plaque was collected from the gingival thirds of the buccal surfaces and from the pit and fissure areas using a Sheppard's hook no. 5 explorer. They were instructed not to eat or drink anything for at least 1 h before the collection of plaque sample. The collected plaque samples were diluted to 1:1000 using sterile peptone for the microbial analysis. A semiquantitative, i.e., four-quadrant streaking method was adopted (Sitges–Serra and Linares).[18] Using a standard loop, the plaque sample was streaked on mitis salivarius bacitracin agar (S. mutans), blood agar (S. sanguinis), and Lactobacillus MRS agar (Lactobacilli). The growth in all the four quadrants was recorded in colony-forming units per ml (CFU/ml).

Administration of mouthwash

The study participants in both the groups were given two bottles of the mouthwash of 500 ml every 15th day, one to be kept in school with the teachers for using in morning after 30 min after breakfast and one to be carried home for night use after 30 min after dinner. Before using the mouthwash, gargling with plain water was done to remove the debris. The study participants were instructed to use 30 ml of mouthwash by holding it in the mouth and then perform active cheek movement for 2 min before expectorating the mouthwash. The teachers and parents were educated and trained in the use of mouthwash so that supervised mouth rinsing was performed by the children for a period of 2 min.[14] The study participants were advised not to eat or rinse for the next 30 min. They were given the compliance checklist to tick mark after every rinse. The emptiness of the bottle of mouthwash was correlated with the number of mouthrinses done.

Follow-up

Plaque, gingivitis scores, and microbiological analysis were recorded at baseline, 1 month, and 3 months.

Statistical analysis

Statistical analysis was done with Statistical Package for the Social Sciences (IBM SPSS Statistic for Windows, version 21.0. Armonk, NY: IBM Corp.). For intragroup comparison, one-way analysis of variance (ANOVA) test followed by Tukey's post hoc test was applied, whereas for intergroup comparison of PI, gingival index, and microbial colony count at 0, 30, and 90 days, un-paired t-test was applied. P < 0.05 was considered for statistical significance.

RESULTS

Table 1 reports the Intragroup and intergroup comparison of mean plaque index scores, gingival index scores, and microbial count among Group A (0.4% Triphala) and Group B (0.02% chlorhexidine) at varying time periods.

Table 1

Intragroup and intergroup comparison of mean plaque index scores, gingival index scores, and microbial count among Group A (0.4% Triphala) and Group B (0.02% chlorhexidine) at varying time periods

Parameters	Group	Mean±SD			P intragroup
		Baseline	1st month	3rd month	Baseline-1 month	Baseline-3 months	1-3 months
Mean plaque index score	Group A (Triphala)	1.08±0.16	0.69±0.15	0.41±0.06	0.001**	0.001**	0.001**
	Group B (CHX)	1.14±0.27	0.75±0.22	0.41±0.03	0.001**	0.001**	0.001**
	P	0.29	0.18	0.83	-	-	-
Mean gingival index score	Group A (Triphala)	1.01±0.16	0.67±0.92	0.30±0.05	0.02*	0.01*	0.001**
	Group B (CHX)	1.07±0.22	0.64±0.22	0.32±0.050	0.001**	0.001**	0.001**
	P	0.27	0.83	0.13	-	-	-
Mean Streptococcus mutans count	Group A (Triphala)	24.22±4.49	20.83±3.71	14.8±2.60	0.001**	0.001**	0.001**
	Group B (CHX)	22.97±3.43	18.61±3.35	14.22±2.07	0.001**	0.001**	0.001**
	P	0.18	0.01*	0.29	-	-	-
Mean Streptococcus sanguinis count	Group A (Triphala)	37.38±5.22	34.13±4.53	39.91±3.84	0.09*	0.05*	0.001**
	Group B (CHX)	36.5±2.46	35.77±6.38	40.69±4.77	0.63	0.02*	0.001**
	P	0.06	0.21	0.45	-	-	-
Mean Lactobacilli count	Group A (Triphala)	12.77±3.65	8.97±2.22	7.8±1.8	0.001**	0.001**	0.16
	Group B (CHX)	12.0±3.95	8.91±3.09	6.58±1.7	0.001**	0.001**	0.001**
	P	0.38	0.93	0.001**	-	-	-

*P<0.0 statistically significant; **P<0.001 statistically highly significant, Tests applied: For intragroup comparison - Oneway ANOVA followed Tukey’s post hoc analysis; for intergroup comparison - Unpaired t-test, Values expressed as mean±SD. SD - Standard deviation; CHX - Chlorhexidine; P - Probability; ANOVA - Analysis of variance

Comparative evaluation of mean plaque index scores in Group A (0.4% Triphala mouthwash) and Group B (0.12% chlorhexidine mouthwash) at varying time periods. *P < 0.05 significant. The mean plaque index scores in Group A (0.4% Triphala mouthwash) and Group B (0.12% chlorhexidine mouthwash) at different time periods were statistically significant (one-way ANOVA, P < 0.05). Tukey's post hoc analysis showed that there was a significant difference in the mean plaque index scores. P – Probability value

Mean plaque index scores in the two groups [Figure 2]

The mean plaque scores for Group A and Group B were 1.08 ± 0.16 and 1.14 ± 0.27 at baseline, 0.69 ± 0.15 and 0.75 ± 0.22 at 1 month, and 0.41 ± 0.06 and 0.41 ± 0.03 at 3 months of follow-up, respectively. The intragroup difference in Group A and Group B was statistically highly significant (P < 0.001) at 1 month and 3 months of follow-up from baseline as well as between 1 month and 3 months, but the intergroup difference between both the groups was not statistically significant (P > 0.05) at the three time intervals.

Comparative evaluation of mean gingival index scores in Group A (0.4% Triphala mouthwash) and Group B (0.12% chlorhexidine mouthwash) at varying time periods. * P < 0.05 significant. The mean gingival index scores in Group A (0.4% Triphala mouthwash) and Group B (0.12% chlorhexidine mouthwash) at different time periods were statistically significant (one-way ANOVA, P < 0.05). Tukey's post hoc analysis showed that there was a significant difference in the mean plaque index scores. P – Probability value

Mean gingival index scores in the two groups [Figure 3]

The mean gingival scores for Group A and Group B were 1.01 ± 0.16 and 1.07 ± 0.22 at baseline, 0.67 ± 0.92 and 0.64 ± 0.22 at 1-month follow-up, and 0.30 ± 0.05 and 0.32 ± 0.050 at 3-month follow-up, respectively. The intragroup difference in Group A was statistically significant (P < 0.05) at 1 month and 3 months of follow-up from baseline and was statistically highly significant (P < 0.001) between 1 month and 3 months. The intragroup difference in Group B was statistically highly significant (P < 0.001) at 1 month and 3 months of follow-up from baseline and between 1 month and 3 months, but the intergroup difference between both the groups was not statistically significant (P > 0.05) at the three time intervals.

Comparative evaluation of mean Streptococcus mutans counts in Group A (0.4% Triphala mouthwash) and Group B (0.12% chlorhexidine mouthwash) expressed as 103 CFU/ml of plaque at varying time periods. *P < 0.05 significant. The mean Streptococcus mutans counts in Group A (0.4% Triphala mouthwash) and Group B (0.12% chlorhexidine mouthwash) at different time periods were statistically significant (one-way ANOVA, P < 0.05). Tukey's post hoc analysis showed that there was a significant difference in the mean plaque index scores. P – Probability value, CFU – Colony-forming units, TCC – Total colony count

Mean Streptococcus Mutans count in the two groups, expressed as 103 CFU/ml of plaque [Figure 4]

The mean total colony counts of S. mutans in Group A and Group B were 24.22 ± 4.49 and 22.97 ± 3.43 at baseline, 20.83 ± 3.71 and 18.61 ± 3.35 at 1-month follow-up, and 14.8 ± 2.60 and 14.22 ± 2.07 at 3-month follow-up, respectively. The intragroup difference in Group A and Group B was statistically highly significant (P < 0.001) at 1 month and 3 months of follow-up from baseline and between 1 month and 3 months, but the intergroup difference between Group A and Group B was statistically significant at 1 month (P < 0.05).

Comparative evaluation of mean Streptococcus Sanguinis counts in Group A (0.4% Triphala mouthwash) and Group B (0.12% chlorhexidine mouthwash) expressed as 103 CFU/ml of plaque at varying time periods. *P < 0.05 significant. The mean Streptococcus sanguinis counts in Group A (0.4% Triphala mouthwash) and Group B (0.12% chlorhexidine mouthwash) at different time periods were statistically significant (one-way ANOVA, P < 0.05). Tukey's post hoc analysis showed that there was a significant difference in the mean plaque index scores. P – Probability value, CFU – Colony-forming units, TCC – Total colony count;

Mean Streptococcus Sanguinis count in the two groups, expressed as 103 CFU/ml of plaque [Figure 5]

The mean total colony counts of S. sanguinis in Group A and Group B were 37.38 ± 5.22 and 34.5 ± 6.46 at baseline, 34.13 ± 4.53 and 35.77 ± 6.38 at 1-month follow-up, and 39.91 ± 3.84 and 40.69 ± 4.77 at 3-month follow-up, respectively, showing an increase in the count from baseline to 3 months in both the groups. The intragroup difference in Group A was statistically significant (P < 0.05) at 1 month and 3 months of follow-up from baseline, but it was statistically highly significant (P < 0.001) between 1 month and 3 months. The intragroup difference in Group B was statistically significant (P < 0.05) between baseline and 3 months and statistically highly significant (P < 0.001) between 1 month and 3 months, but the intergroup difference between both the groups was not statistically significant (P > 0.05) at the three time intervals.

Comparative evaluation of mean Lactobacilli counts in Group A (0.4% Triphala mouthwash) and Group B (0.12% chlorhexidine mouthwash) expressed as 103 CFU/ml of plaque at varying time periods. *P < 0.05 significant. The mean Lactobacilli counts in Group A (0.4% Triphala mouthwash) and Group B (0.12% chlorhexidine mouthwash) at different time periods were statistically significant (one-way ANOVA, P < 0.05). Tukey's post hoc analysis showed that there was a significant difference in the mean plaque index scores. P – Probability value, CFU – Colony-forming units, TCC – Total colony count

Mean Lactobacilli count in the two groups, expressed as 103 CFU/ml of plaque [Figure 6]

The mean total colony counts of Lactobacilli in Group A and Group B were 12.77 ± 3.65 and 12.0 ± 3.95 at baseline, 8.97 ± 2.22 and 8.91 ± 3.09 at 1-month follow-up, and 7.8 ± 1.8 and 6.58 ± 1.7 at 3-month follow-up, respectively. The intragroup difference in Group A and Group B was statistically highly significant (P < 0.001) at 1 month and 3 months of follow-up from baseline. The intergroup difference between Group A and Group B was statistically highly significant (P < 0.001) at 3 months of follow-up.

DISCUSSION

A direct relationship has been demonstrated between plaque levels and the severity of gingivitis.[2] The S. mutans, S. sanguinis, and Lactobacilli species are found in high concentration in dental plaque as compared to saliva; therefore, direct plaque samples were collected and analyzed for the above-stated microorganisms.

Children are easily accessible in schools and are known to often practice inadequate oral hygiene measures and experience gingivitis;[19] therefore, 14–15-year-old schoolchildren were selected.

The antimicrobial efficacy of aqueous extract of Triphala was established in the in vitro phase of the study, which showed a minimal inhibitory concentration of 0.4% for S. mutans, S. sanguinis, and Lactobacilli. CHX rinses are often used as a benchmark control.[20] The two most common concentrations commercially available are 0.2% and 0.12%. In the study, 0.12% CHX was used with the rationale to reduce side effects when maintaining comparable efficacy as the total amount of CHX is approximately the same: 10 mL of 0.2% CHX contains 20 mg and 15 mL of 0.12% CHX contains 18 mg per volume.[10]

Intragroup effect on plaque

The results of the study participants in Group A and in Group B indicated a significant reduction in PI scores when the means were compared at different time intervals. For Group A, the mean PI, which was 1.08 (±0.16) at baseline, reduced to 0.69 (±0.15) at 1 month and to 0.41 (±0.06) at 3 months, with statistically highly significant differences (P < 0.001) at 1 month and 3 months from baseline. These results could be attributed to tannic acid which gets adsorbed well onto the hydroxyapatite of the tooth by binding the anionic groups on the bacterial cell wall, leading to protein denaturation and subsequently resulting in cell death.[21]

For Group B, the mean PI, which was 1.14 (±0.27) at baseline, reduced to 0.75 (±0.22) at one month and to 0.41 (±0.03) at 3 months, with statistically significant differences (P < 0.05) at 1 month and 3 months from baseline. This result could be attributed to substantivity of CHX. The tooth surface-bound CHX due to its bacteriostatic effect interferes with the bacterial adherence on the tooth surface, thus preventing plaque formation.[22]

Intragroup effect on gingivitis: A significant parallel reduction of GI scores was seen among the study participants of Group A and Group B when the means were compared at different time intervals. For Group A, the mean gingival index scores reduced from 1.0 (±0.16) at baseline to 0.67 (±0.92) at 1 month and to 0.30 (±0.05) at 3 months, with statistically significant differences (P < 0.05). The result could be attributed to the inhibitory activity of Triphala against matrix melano-proteins-9, seen in pathologically elevated collagenases associated with gingival and periodontal disease.[11]

For Group B, the mean GI scores were 1.07 (±0.22) at baseline to 0.64 (±0.57) at 1 month and to 0.32 (±0.05) at 3 months, with statistically highly significant differences (P < 0.001). The reduction in gingivitis may be parallel to the reduction in plaque due to the antiplaque action of CHX.

Intergroup effect on plaque and gingivitis: The intergroup comparison done at baseline, 1 month, and 3 months showed that the mean plaque and gingival scores in Group A and Group B were not statistically significant (P > 0.05), suggesting that both mouthwashes had the same inhibitory effect on plaque and gingivitis. Similar results for plaque scores were obtained in the studies conducted by Desai et al.[11] and Naiktari et al.,[20] whereas contrasting results were observed in the study conducted by Bajaj et al.[14] Bhattacharjee et al.[23] while for gingivitis study conducted by Bajaj et al.,[14] Naiktari et al.[20] and Bhattacharjee et al.[23] showed similar results.The difference may be due to the duration of the study period where CHX was more effective in short-term studies, whereas Triphala had better efficacy over a long period of time.

Effect on microbial count: The mean S. mutans and Lactobacilli counts in plaque in Group A and Group B study participants showed a significant reduction at follow-up. For Group A, the mean S. mutans and lactobacilli counts in plaque showed statistically highly significant differences (P < 0.001) at 1 month and 3 months from baseline. The antimicrobial activity of Triphala can be attributed to the presence of gallic acid, Vitamin C, ellagic acid, chebulic acid, bellericanin, β-sitosterol, and flavonoids present in Triphala as they inhibit the growth of Gram-positive and Gram-negative bacteria.[24]

For Group B, the mean S. mutans and Lactobacilli counts in plaque showed statistically highly significant differences (P < 0.001) at 1 month and 3 months from baseline.

An apparent antagonism was observed between S. sanguinis and S. mutans count (Pearson's correlation: -0.138), suggesting that the colonization of S. sanguinis may influence the subsequent colonization of S. mutans, and this, in turn, may suggest several ecological approaches toward controlling dental caries.[5]

The intergroup comparison done at baseline, 1 month, and 3 months showed that the mean S. mutans and S. sanguinis counts in Group A and Group B were not statistically significant (P > 0.05), suggesting that both mouthwashes had the same antibacterial activity at the end of the study which was in consensus with the study done by Bajaj et al.[14] The CHX mouthwash was more effective than Triphala mouthwash in reducing mean Lactobacilli count at 3 months of follow-up, which was in contrast to the study conducted by Bajaj et al.[14]

Limitations of the study

The participants in this clinical trial may experience Hawthorne effect and novelty effect. The experimental period was an extended period of 3 months; still, further long-term studies with a larger sample size as well as including government schools and government-aided schools must be performed to evaluate the antimicrobial, antigingivitis, and antiplaque effects of Triphala and CHX mouthwash.

CONCLUSION

Triphala (0.4%) and CHX (0.12%) mouthwash showed a similar trend in preventing plaque formation and in anti-inflammatory effect on gingival health with no evident side effects after 90 days of use. Hence, the use of medicinal plants against oral diseases can be a viable alternative to other antimicrobial agents as they offer a cheap and effective module in controlling plaque and bacteria responsible for oral infections.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.