|Year : 2011 | Volume
| Issue : 1 | Page : 29-32
A comparative evaluation of efficacy of Punica granatum and chlorhexidine on plaque and gingivitis
Sakshi Ahuja1, Vidya Dodwad1, Bhavna Jha Kukreja1, Praful Mehra2, Pankaj Kukreja3
1 Department of Periodontics, ITS-CDSR, Muradnagar, Ghaziabad, Uttar Pradesh, India
2 Department of Prosthodontics, ITS-CDSR, Muradnagar, Ghaziabad, Uttar Pradesh, India
3 Department of Oral and Maxillofacial Surgery, ITS-CDSR, Muradnagar, Ghaziabad, Uttar Pradeshh, India
|Date of Web Publication||29-Jul-2013|
B-43, Sarvodaya Enclave, New Delhi - 110017
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Periodontal diseases are chronic bacterial infections that lead to gingival inflammation, periodontal tissue destruction, and alveolar bone loss. Acting as powerful allies in the fight against periodontal disease, natural compounds can help safeguard against lethal age-related diseases that emanate from our mouths. Punica granatum (pomegranate) shrub belongs to the Punicaceae family which has been used as an astringent, hemostatic, antidiabetic, antihelmintic, and also for diarrhea and dysentery. The aim of the present work was to investigate the possible efficacy of hydroalcoholic extract from Punica granatum fruit as an antiplaque and antigingivitis agent when compared with chlorhexidine. Materials and Methods: Twenty subjects diagnosed with chronic generalized gingivitis were selected and randomly divided into two groups: Group 1 - Pomegranate mouthwash and Group 2 - Chlorhexidine mouthwash. Punica granatum mouthwash was prepared using raw Punica granatum fruit. Patients were instructed to use the prescribed mouthwash for 15 days. Clinical evaluation was undertaken using the gingival index, the plaque index, and bleeding on probing at baseline, 7 days, and 15 days. Results: The clinical study observed significant improvement in gingival status in both the sites (P<0.05). Subjects using Punica granatum mouthwash showed significant improvement in bleeding and gingivitis score as compared with chlorhexidine. In contrast, Punica granatum was shown not to be so effective in reducing plaque scores. Chlorhexidine still remains as a standard in the reduction of plaque in subjects with gingivitis. Conclusion: Punica granatum mouthwash is beneficial in improving gingival status due to its profound styptic action, with sufficient reduction in plaque scores.
Keywords: Chlorhexidine, gingivitis, mouthwash, Punica granatum, plaque
|How to cite this article:|
Ahuja S, Dodwad V, Kukreja BJ, Mehra P, Kukreja P. A comparative evaluation of efficacy of Punica granatum and chlorhexidine on plaque and gingivitis. J Int Clin Dent Res Organ 2011;3:29-32
|How to cite this URL:|
Ahuja S, Dodwad V, Kukreja BJ, Mehra P, Kukreja P. A comparative evaluation of efficacy of Punica granatum and chlorhexidine on plaque and gingivitis. J Int Clin Dent Res Organ [serial online] 2011 [cited 2020 Aug 9];3:29-32. Available from: http://www.jicdro.org/text.asp?2011/3/1/29/115776
| Introduction|| |
Gingivitis is a chronic inflammatory process limited to the gingiva without either attachment loss or alveolar bone loss. It is one of the most frequent oral diseases, affecting more than 90% of the population, regardless of age, sex, or race.  Plaque is the primary etiological factor in gingival inflammation.  So, daily and effective supragingival plaque control using tooth brushing and dental floss is necessary to arrest its progression to periodontitis.
Although mechanical plaque control methods have the potential to maintain adequate levels of oral hygiene, studies have shown that such methods are not being employed accurately.  Therefore, several chemotherapeutic agents such as triclosan, essential oils, and chlorhexidine have been developed to control bacterial plaque. Among these, chlorhexidine has been the gold standard since ages due to its profound antibacterial and antiplaque activity.
As a consequence of the side effects of chlorhexidine, various herbal products (like Astronium urundeuva, Calendula , Aloe vera, Curcuma zedoaria) have been tested with effective results. Among these, one of the recent herbal products is Punica granatum, which literally translates to seeded ("granatus") apple ("pomum"). Punica granatum Linn belongs to family Punicaceae, mostly known as "pomegranate." It is a shrub native from Asia where several of its parts have been used as an astringent, haemostatic, and for diabetes control.  The genus name, Punica, was the Roman name for Carthage, where the best pomegranates were known to grow. The aim of the present work was to investigate the possible efficacy of hydroalcoholic extract (HAE) from Punica granatum fruit as an antiplaque and antigingivitis agent when compared with chlorhexidine.
| Materials and Methods|| |
This study was conducted in ITS-CDSR on 2 voluntary patients from both sexes (10 females and 10 males), age ranging from 14 to 25 years, with moderate gingivitis. Patients with systemic disorders, subjects under antimicrobial therapy, smokers, and pregnant women were excluded from the study. Individuals were given the same type of toothbrush and toothpaste with standardized brushing technique instructions. After thorough scaling and polishing, the subjects were randomly distributed into the following 2 groups:
- Group 1 (n = 10): Subjects were instructed to use 10 ml of Punica granatum mouthwash twice daily for 15 days.
- Group 2 (n = 10): Subjects were instructed to use 10 ml of 0.2% chlorhexidine mouthwash (HEXIDINE by ICPA) twice daily for 15 days.
Preparation of Punica granatum mouthwash
The HAE was prepared from whole fresh fruits (4-5 fruits) that were cut into small pieces and blended with a mixture of ethanol and distilled water (1 : 1, v/v). The material was filtered through several layers of gauze, and evaporated at 60°C to one-third of its original volume or until all the ethanol evaporated. The volume was restored with distilled water, and 1 ml sample was completely evaporated in the oven, in order to get the insoluble residues/ml (used to express the final hydroalcoholic concentration, which ranged between 50 and 60 mg/ml), which was further used to adjust the concentration of mouthwash [Figure 1].
Data were collected at baseline, 7 days, and 15 days utilizing the indices, i.e.,
- Plaque index by Turskey Gilmore Glickman modification of Quigley Hein plaque index, 
- Gingival index by Loe and Silness  and
- Bleeding on probing by Ainamo and Bay. 
Student t test was used for inter-group and intra-group comparison. P value was adjusted at <0.05.
| Results|| |
A total of 20 participants (10 females and 10 males) participated in the study with the mean age of 21.3 ± 0.2134 years without any dropouts.
On analyzing the gingival index, it was seen that both the groups led to significant reduction in gingival scores (P<0.05). Mean decrease in pomegranate group was from 1.653 ± 0.1675 at baseline to 1.211 ± 0.1081 at 7 days and 0.928 ± 0.1823 at 15 days with % reduction of 26.74% and 43.86%, respectively (P<0.05). Significantly less reduction was seen in chlorhexidine group, i.e., from 1.641 ± 0.1761 at baseline to 1.295 ± 0.1686 at 7 days and 0.991 ± 0.2393 at 15 days with % reduction of 21.04% and 39.61%, respectively (P<0.05). Hence, pomegranate mouthwash was a more effective antigingivitis agent as compared with chlorhexidine [Table 1] and [Figure 2].
|Figure 2: Comparison of plaque index between Punica granatum and|
chlorhexidine mouthwash within 15 days
Click here to view
|Table 1: Gingival index of Punica granatum and chlorhexidine group at baseline, 7th day, and 15th day|
Click here to view
Comparison of Plaque index between pomegranate and pomegranate mouthwash revealed that significantly more reduction in plaque score was seen in chlorhexidine group as compared with pomegranate [P<0.05; [Table 2] and [Figure 3]. Mean ± SD for pomegranate group has decreased from 3.941 ± 0.257 at baseline to 3.498 ± 0.4206 at 7 days and 3.069 ± 0.4577 at 15 days with % reduction of 11.24% and 22.13%, respectively (P<0.05). Significantly greater reduction was seen in chlorhexidine group, i.e., from 3.882 ± 0.42918 at baseline to 3.26 ± 0.4356 at 7 days and 2.667 ± 0.6360 at 15 days with % reduction of 16.02% and 31.3%, respectively (P<0.05).
|Figure 3: Comparison of gingival index between Punica granatum and chlorhexidine mouthwash within 15 days|
Click here to view
|Table 2: Plaque index of Punica granatum and Chlorhexidine group at baseline, 7th day, and 15th day|
Click here to view
Bleeding on Probing
Analysis of bleeding on probing revealed mean decrease in pomegranate group from 0.77 ± 0.0948 at baseline to 0.26 ± 0.843 at 7 days and 0.14 ± 0.069 at 15 days with % reduction of 66.2% and 81.8%, respectively (P<0.05). Lesser reduction in bleeding scores was seen in chlorhexidine group, i.e., from 0.781 ± 0.0952 at baseline to 0.529 ± 0.09983 at 7 days and 0.293 ± 0.578 at 15 days with % reduction of 32.27% and 62.48%, respectively (P<0.05). Pomegranate, being a profound styptic, leads to significant reduction in bleeding on probing as compared with chlorhexidine [Table 3] and [Figure 4].
|Figure 4: Comparison of bleeding on probing between Punica granatum and chlorhexidine mouthwash within 15 days|
Click here to view
|Table 3: Plaque index of Punica granatum and chlorhexidine group at baseline, 7th day, and 15th day|
Click here to view
| Discussion|| |
Though around 6 000 plants in India are used in herbal medicines, little research has been conducted on efficacy, safety, and properties of herbal products. Over the decades, very few studies have been conducted to show the clinical efficacy of Punica granatum. In the present study, it was demonstrated that hydroalcoholic extract from pomegranate fruit exerted a significant reduction in clinical parameters.
Analysis of plaque index values suggests that both the mouthwashes were helpful in reducing it but chlorhexidine reduced plaque scores to greater extent as compared with pomegranate mouthwash group. These findings are in agreement with the studies by Overholser et al. and Haffajee et al.  In a microbiological study, Menezes et al. showed that after 1 minute mouth rinsing, more reduction in plaque was observed with Punica granatum (84%) as compared with chlorhexidine (79%),  contradicting our results. The differences in the results may be because of difference in the methodology employed, i.e., instead of plaque index, colony-forming units were taken into consideration. Another reason could be that the duration of their study was very short and they recorded reduction only after a single mouth rinsing session.
Analysis of gingival index scores revealed that Punica granatum was more efficient in reducing gingival score and bleeding on probing as well due to its strong styptic action. Similar results were reported by Hafajee et al.  A study by Salgado et al. in 2006 on 10% Punica granatum gel does not support our finding as this gel was not efficient in preventing supragingival dental plaque formation and gingivitis.  Gel was placed into tooth shield in a non-diluted form; it may be speculated that gel solubilization with saliva would be necessary for its antimicrobial action to take place. In our study, direct interaction of saliva to Punica granatum led to acceptable results.
In an urge of looking for better antiplaque and antigingivitis agents with limited side effects as compared with chlorhexidine, various herbal products have been tried with fruitful results. Punica granatum is a recent herbal product used in field of dentistry. So, more clinical and microbiological studies on a long-term basis are required to know the precise effectiveness of this product.
| Conclusion|| |
In the absence of vigilant oral care, plaque and tartar will build up, resulting in gingivitis and possibly progressing to periodontitis. So, various herbal products have been tried and have shown promising results with minimal side effects. Also, their additional effect on inflammatory pathways and antioxidant potential make them eligible to be used as effective antigingivitis agents. An explosion of interest in the numerous therapeutic properties of Punica granatum over the last decade has led to numerous in vitro, animal, and clinical trials. Our study concluded that Punica granatum is a better antigingivitis agent than chlorhexidine, but not as effective against dental plaque as chlorhexidine. The treatment with Punica granatum could be used as it is easy to prepare, has profound styptic action, and shows acceptable reduction in plaque scores. More clinical trials are required to know the effectiveness of Punica granatum and its advantage over the prototype chemical plaque control agent, i.e., chlorhexidine, which is still a gold standard for reduction of plaque scores.
| Acknowledgment|| |
Our sincere thanks to Dr. Y Kumar, Director and Head of Department, Department of Pharmacy of I.T. S dental college, for helping us prepare the pomegranate mouthwash.
| References|| |
|1.||Salgado AD, Maia JL, Pereira SL, de Lemos TL, Mota OM. Antiplaque and antigingivitis effects of a gel containing Punica granatum Linn extract: a double-blind clinical study in humans. J Appl Oral Sci 2006;14:162-6. |
|2.||Loe H, Theilade E, Jensen SB. Experimental gingivitis in man. J Periodontol 1965;36:177-87. |
|3.||Menezes SM, Cordeiro LN, Viana GS. Punica granatum (pomegranate) extract is active against dental plaque. J Herb Pharmacother 2006;6:79-92. |
|4.||Turskey S, Gilmore ND Glickman I. Reduced plaque formation by thechloromethyl analogue of vitamin C. J Periodontol 1970;41:41-3. |
|5.||Loe H, Silness J. Periodontal disease in pregnancy. I. Prevelance and severity. Acta Odontolgica Scand 1963;21:533-51. |
|6.||Ainamo J, Bay I. Problems and proposals for recording gingivitis and plaque. Int Dent J 1975;25:229-35. |
|7.||Overholser CD, Meiller TF, DePaola LG, Minah GE, Niehaus C. Comparative effects of 2 chemotherapeutic mouthrinses on the development of supragingival dental plaque and gingivitis. J Clin Periodontol 1990;17:575-9. |
|8.||Haffajee AD, Yaskell T, Socransky SS. Antimicrobial Effectiveness of an Herbal Mouthrinse Compared With an Essential Oil and a Chlorhexidine Mouthrinse. J Am Dent Assoc 2008;139:606-11. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3]