|Year : 2013 | Volume
| Issue : 6 | Page : 546-549
|An in-vivo comparative evaluation of two herbal extracts Emblica officinalis and Terminalia Chebula with chlorhexidine as an anticaries agent: A preliminary study
Arumugam Velmurugan1, Manavalan Madhana Madhubala2, Sreekrishnapillai Bhavani1, Kasinathan Subbaian Satheesh Kumar1, Srinivasan Sai Sathyanarayana1, Natanasikamani Gurucharan1
1 Department of Conservative Dentistry and Endodontia, Rajah Muthiah Dental College and Hospital, Annamalai University, Chidambaram, Chennai, Tamil Nadu, India
2 Department of Conservative Dentistry and Endodontia, SRM Dental College, SRM University, Ramapuram, Chennai, Tamil Nadu, India
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|Date of Submission||20-Apr-2013|
|Date of Decision||19-Jul-2013|
|Date of Acceptance||24-Aug-2013|
|Date of Web Publication||2-Nov-2013|
| Abstract|| |
Aim: To compare the effect of 20% aqueous extract of Terminalia chebula and Emblica officinallis with chlorhexidine as an anticaries mouthwash - an in vivo study.
Methodology: 20% aqueous extract of Terminalia chebula and Emblica officinalis were prepared. Forty five high caries risk patients were divided into group 1,2,3 [ n=15]and asked to rinse with 20% aqueous extract of Terminalia chebula and Emblica officinalis, 0.2% Chlorhexidine for 40 seconds respectively. Salivary samples were collected for pH, buffering capacity before and after rinsing at repeated intervals of 10, 30,60 and 90 minutes and except for microbial analysis for which it was collected before and 90 minutes after rinsing. The pH and the buffering capacity analysis was done using chairside kit and percentage of reduction of Streptococcus mutans and Lactobacillus were tabulated and statistically analyzed.
Results: For salivary pH, Group 2 showed the highest peak value followed by group 1. For salivary buffering capacity,there was no significant difference between any of the groups. For microbial count, highest percentage of reduction was seen in group 2 followed by group 1 and 3. However group 3 was more efficient at 90 minutes followed by group 1 and group 2.
Conclusion: The aqueous extract of Embilica officinalis extract and Terminalia chebula was more effective anticaries mouthwash but with less time of action than chlorhexidine.
Keywords: Anticaries mouthwash; chlorhexidine; Emblica officinalis; Terminalia chebula
|How to cite this article:|
Velmurugan A, Madhubala MM, Bhavani S, Satheesh Kumar KS, Sathyanarayana SS, Gurucharan N. An in-vivo comparative evaluation of two herbal extracts Emblica officinalis and Terminalia Chebula with chlorhexidine as an anticaries agent: A preliminary study. J Conserv Dent 2013;16:546-9
|How to cite this URL:|
Velmurugan A, Madhubala MM, Bhavani S, Satheesh Kumar KS, Sathyanarayana SS, Gurucharan N. An in-vivo comparative evaluation of two herbal extracts Emblica officinalis and Terminalia Chebula with chlorhexidine as an anticaries agent: A preliminary study. J Conserv Dent [serial online] 2013 [cited 2020 Apr 8];16:546-9. Available from: http://www.jcd.org.in/text.asp?2013/16/6/546/120958
| Introduction|| |
The management of dental caries is aimed to limit tooth demineralization by modifying the dietary habits, inhibiting or modifying oral microbial growth, altering the salivary pH and buffering capacity. The main etiological agents of dental caries are Streptococcus mutans and Lactobacillus species.  They can easily colonize the tooth surface and initiate acid production by synthesizing extracellular polysaccharides from sucrose foods.  Hence, a caries prevention program primarily should be aimed at reducing the cariogenic bacteria.
A mouth rinse is a chemotherapeutic agent used as an effective home care remedy to enhance oral hygiene and prevent dental caries by targeting the cariogenic bacteria. A variety of synthetic antimicrobial mouthwashes are available to prevent dental caries. It was shown to inhibit plaque formation, also reduce gingival inflammation and prevent dental caries.  Chlorhexidine, the most common mouth rinse has been shown to effectively reduce the level of oral S. mutans.  However, studies for the anticariogenic activity of chlorhexidine as a mouth rinse had reported large variations, inconsistencies and an inability to ablate S. mutans in the oral cavity. ,
The usage of antimicrobial herbal products in dentistry has been well documented in prevention of dental caries. ,, In spite of various commercially available anticaries agents, the search for an effective herbal antimicrobial mouth wash still continues. Hence in this study, we compared the aqueous extracts of two medicinal plants Emblica officinalis and Terminalia chebula as a mouthwash, on their efficacy against dental caries.
E. officinalis is commonly called by several names such as amalaka, oval, amla, amlaki and Indian gooseberry. It consists of the following constituents such as phenols, tannins, polyphenols, flavonoids, kaempferol, ellagic acid and gallic acid.  They have the potential to prevent dental caries by inhibiting the virulence factors of S. mutans and Lactobacillus. 
T. chebula is a medicinal plant known as Kadukka in Tamil. The chief constituents are hydrolysable tannins (13%) such as gallic acid, chebulic acid, chebulagic acid and corilagin.  These acids are found to have antibacterial activity against cariogenic bacteria.  In our previous study, we proved that T. chebula as an effective anticaries mouthwash. 
Only few studies , on clinical trials of herbal mouth washes are available. Clinical trials with herbal extracts can be a potential source for the development of a phytomedicine to act against dental caries. There are no clinical trials on comparison between the anticariogenic potential of two herbal extracts of T. chebula and E. officinalis. Hence, we aimed to evaluate and compare the effect of 20% aqueous extract of T. chebula and E. officinalis and 0.2% chlorhexidine when used as an anticaries mouthwash. The objective of the study was to check the change in the salivary pH, buffering capacity and reduction in microbial count of the saliva before and after rinsing with the 20% aqueous extract of T. chebula and E. officinalis and 0.2% chlorhexidine as a mouthwash in high caries risk individuals.
| Materials and Methods|| |
Preparation of the T. Chebula extract
The dried ripe fruit of T. chebula was obtained and ground into a fine powder. It was suspended in 10 times its quantity of sterile distilled water in a round bottomed flask and kept at 4°C for 72 h. Then, the aqueous extract was decanted, clarified by filtration through a muslin cloth and evaporated in a flat bottomed porcelain dish at 40°C. The dried extract (100 g) was again suspended in polyethylene glycol and distilled water (400 ml) and evaporated to get the final concentrate. This concentrate was then diluted with sterile distilled water to get a mouth rinse of 20% (w/v) concentration.
Preparation of the E. officinalis extract
The leaves of E. officinalis were obtained and ground into a fine powder and the same above mentioned method of preparation was followed.
A total of 45 patients who satisfied the selection criteria of high caries risk group were included in the study. All patients subjected for the study were informed about study protocols and written consent was obtained. They were randomly divided into three groups each containing 15 patients (n = 15); Group 1-20% aqueous extract of T. chebula mouth wash; Group 2-20% aqueous extract of E. officinalis mouth wash; Group 3-0.2% chlorhexidine mouth wash.
Patients were asked to wash and retain the respective mouth rinse in the mouth for 40 Secs before expectorating it. Patients were not allowed to consume any diet or drink orally for following 90 mins. A salivary sample from each patient was collected for pH, buffering capacity before (pre-rinse) and after rinsing (post-rinse) at repeated intervals of 10, 30, 60 and 90 mins however for microbial analysis, saliva was collected only after 90 mins. The mouth rinsing procedure and collection of salivary samples were handled by one investigator and analysis of the salivary parameters was carried out by different investigator who was not aware of the experimental groups to blind the study.
Salivary pH and buffering capacity analysis
Salivary pH analysis was performed using chair side kit (M-S Saliva Check Buffer Kit (GC America Inc.)). Unstimulated saliva was collected and the pH test paper was dipped in the sample for 10 Secs and the color changes were compared with the chart provided by the manufacturer and the values were recorded.
Salivary buffering capacity was performed using the same chair side kit. Stimulated saliva was collected after instructing the patient to chew paraffin wax for 30 Secs and one drop of saliva was placed onto each test pads using the pipette provided by the manufacturer. After 2 mins, the color of the strip was compared with the chart provided by the manufacturer and the values were recorded.
Pre-rinse and post-rinse salivary samples after 90 mins were collected in the same manner as was carried out for the salivary buffering capacity analysis. The culture medium used for S. mutans was Mitis Salivarius agar and for Lactobacilli was Lactobacilli agar. The technique used for assessing microbial analysis was the Dilution and Spread plate technique. The saliva samples were diluted and streaked on petri plates followed by incubation for 72 hrs at 35°C. After incubation, the colony forming units were recorded and mean percentage of reduction (PR) was calculated.
The results were tabulated and statistically analyzed using one-way analysis of variance followed by Tukey HSD post-hoc test (GraphPad Software, 2003 INSTAT INC, VERSION 3.06).
| Results|| |
[Table 1] shows the results of pH analysis. All the groups showed a significant difference between the pre-rinse and post-rinse group. On comparing the groups at various time intervals
Buffering capacity analysis
- At 10, 30 and 60 mins, there was no significant difference among groups (P > 0.05).
- At 90 mins, there was high significant difference between Group 1 and 3 (P < 0.01) with Group 3 showing higher values of 6.88.
- In Group 3, there was a gradual increase in pH till 90 mins with a significant difference between 10 mins and 90 mins whereas in other groups there is no significant difference at various time intervals.
[Table 2] shows the results of buffering capacity analysis. All the groups showed a significant difference between the pre-rinse and post-rinse group. On comparing the groups at various time intervals,
- At 10 mins, there was no significant difference among groups
- At 30, 60, 90 mins, there was no significant difference between Groups 2 and 3.
- At 30, 60, 90 mins, Group 1 showed significantly less rise in pH when compared to other groups.
- Group 3 exhibited highest buffering capacity with no significant difference at all time intervals.
- Groups 1 and 2 showed a gradual decrease in the buffering capacity over increase in time.
[Table 3] shows the mean PR of S. mutans and Lactobacillus. There was a significant PR between the pre-rinse and post-rinse samples. E. officinalis showed highly significant antibacterial activity compared with chlorhexidine and T. chebula against S. mutans. E. officinalis (76.6%) and T. chebula (71.7%) showed antibacterial activity against Lactobacillus with no significant difference. Chlorhexidine showed least PR (65%, 64%) against both the species when compared with the other two herbal extracts.
| Discussion|| |
The changes in the salivary pH, buffering action and microbial activity before and after use of experimental mouthwashes were assessed because three quantitative actions play a major role in the caries disease process. The time intervals of 10, 30, 60 and 90 mins were selected for convenience and to evaluate the effect of mouthwash over a period of time. 
Chlorhexidine gluconate, which is charged positively, shows high affinity for negative ions found in cell membranes of microorganisms. It indirectly affects the enzymatic function of dehydrogenase and adenosine triphosphatase present in the cell wall of bacteria resulting in the disruption of cell membrane.  It is evident in this study that the chlorhexidine showed a definite reduction in the microbial activity and an increase in the pH and buffering capacity resulting in marked anticariogenic effect. However, there is a lack of convincing clinical data and long-term clinical evidence for caries prevention with chlorhexidine.  Moreover, chlorhexidine have reports of causing discoloration effects  and an unpleasant taste. 
The evidence of efficacy of synthetic antimicrobial agents as mouthwashes remains obscure for higher caries risk group people.  Hence, two medicinal plants of known and higher inhibitory action against common cariogenic pathogens were selected for this study to compare its efficacy with chlorhexidine. In this study, T. chebula and E. officinalis proved to be an effective anticaries mouthwash owing to its ability to increase salivary pH, buffering capacity and to inhibit S. mutans and Lactobacilli. The microbial reduction in Groups 1 and 2 may be attributed to the presence of tannins and flavonoid.
The action of tannin may induce cytotoxic action on the cell membranes of the microorganisms. The astringent characters of tannin may induce complexation with enzymes or substrates. Inhibition of the electron transport system was observed following treatment with tannic acid. The complexation of metal ions by tannins could be the other possible mechanism responsible for tannin toxicity. 
Flavonoids, group of phenols, proved to be anticariogenic by the presence of anti-glucosyltransferases activity.  The binding of active components of E. officinalis extract to the proteins associated with the bacterial cell surface leads to reduction in hydrophobic adherence of S. mutans to the tooth surface.  The suppression of virulence gene, which is responsible for plaque cohesion leading to dental caries, attenuates quorum sensing mechanism resulting in despaired virulence expressions. 
Both the plant extracts showed a gradual decrease in pH until 90 mins while chlorhexidine showed a gradual increase in pH among other groups owing to its substantivity. Although the herbal extracts were more rapid and effective at 10 mins, there was a gradual fall in pH as time increases. Buffering capacity results showed no significant difference among three groups at 10 mins. At 30, 60 and 90 mins, E. officinalis and chlorhexidine showed an equal buffering capacity followed by T. chebula. Chlorhexidine showed same buffering activity at all-time intervals owing to its substantivity whereas T. chebula and E. officinalis showed a gradual decrease in buffering capacity over time. Thus a gel or varnish based application of T. chebula and E. officinalis would have more beneficial effect as salivary buffering agent.
The antimicrobial efficiency was highest for E. officinalis followed by T. chebula and chlorhexidine. The aqueous extract of T. chebula strongly inhibits the growth, sucrose induced adherence and glucan induced aggregation of S. mutans. , The 0.6% Triphala (T. chebula and E. officinalis combination) and 0.1% Chlorhexidine had been shown to have an inhibitory effect on plaque, gingivitis and growth of S. mutans and Lactobacillus. , This is in accordance with our study, which showed 67.8 and 71.7% reduction of S. mutans and Lactobacillus respectively, at the same time, chlorhexidine was less effective against Lactobacilli than E. officinalis and T. chebula. Thus, herbal extract can be suggested for management of dentinal caries as their action on Lactobacillus is more than chlorhexidine.
| Conclusion|| |
The aqueous extract of E. officinalis and T. chebula was more effective as a mouth rinse, but with less time of action than chlorhexidine. The future studies have to be aimed at increasing the substantivity of herbal mouthwashes so that they could be a potential alternative to 0.2% chlorhexidine mouthwash alone with intense antimicrobial and cost-effective preventive strategies for dental caries.
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Department of Conservative Dentistry and Endodontia, Rajah Muthiah Dental College, Annamalai University, Chidambaram,Tamil Nadu
Source of Support: None, Conflict of Interest: None
[Table 1], [Table 2], [Table 3]
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