|Year : 2022 | Volume
| Issue : 4 | Page : 847-852
Comparative efficacy of coconut oil-pulling therapy versus 0.2% chlorhexidine mouthrinse on dental plaque and gingival health: A clinicomicrobiological study
Arun Malik1, Priyanka Chopra1, Shalini Kapoor2, Sujata Massamati3
1 Private Practitioner, Faculty of Dental Sciences, SGT University, Gurugram, Haryana, India
2 Department of Periodontology, Faculty of Dental Sciences, SGT University, Gurugram, Haryana, India
3 Department of Periodontology, IDST Dental College, Modinagar, Uttar Pradesh, India
|Date of Submission||22-Jan-2019|
|Date of Acceptance||02-Feb-2021|
|Date of Web Publication||10-Feb-2023|
Dr. Shalini Kapoor
Professor, Department of Periodontology, SGTU University, Chandu-Budhera, Gurugram – Badli Road, Gurugram - 122 505, Haryana
Source of Support: None, Conflict of Interest: None
Introduction: Periodontitis is an inflammatory microbial disease caused by complex of microbes. Prevention and control of periodontal disease must be based on the regular and complete removal of bacterial plaque n.Various modes of mechanical and chemical means of plaque control exist Conventionally, essential oils have also been used to cure many oral conditions. Many oils have been investigated for their effectiveness as anti plaque and anti gingivitis agents. Very few studies have used coconut oil or this purpose. Aim: The present study was undertaken with the aim to investigate the efficacy of virgin coconut oil pulling therapy versus 0.2% CHX mouthrinse and their effect on clinical parameters and total microbial load in salivary sample of periodontally healthy volunteers. Material and Methods: A total of 30 periodontally healthy volunteers with the age range of 18–45 years were randomly divided into two groups:-Group 1:virgin coconut oil mouthrinse (Plant Lipids®, Cochin, India) and Group 2: 0.2% CHX mouthrinse (Clohex Plus®, Dr Reddy's, India). Clinical parameters such as Plaque Index (PI), Gingival Index (GI), and Gingival Bleeding Index (GBI) were recorded for all the subjects. An unstimulated salivary sample was collected in a sterile calibrated bottle and sent for baseline examination of oral microbial load. Subjects were asked to perform oil pulling in (Group 1) and 0.2% CHX rinse in (Group 2) in front of the instructor and were asked to continue for rest of the trial period in the same manner. Results: The mean PI at day 10, day 21, and day 30 was significantly more among coconut oil than CHX group. The mean CFU at day 10, day 21, and day 30 was significantly more among coconut oil than the CHXgroup. Conclusion: Both the study groups showed reductions in PI, GI, and GBI scores, higher reductions were seen in the CHX group.It was observed that CHX and virgin coconut oil were effective against microorganisms, thus causes a reduction in CFU and thus serve as a good alternative.
Keywords: Oil pulling, Colony forming unit, Chlorhexidine, periodontitis
|How to cite this article:|
Malik A, Chopra P, Kapoor S, Massamati S. Comparative efficacy of coconut oil-pulling therapy versus 0.2% chlorhexidine mouthrinse on dental plaque and gingival health: A clinicomicrobiological study. J Datta Meghe Inst Med Sci Univ 2022;17:847-52
|How to cite this URL:|
Malik A, Chopra P, Kapoor S, Massamati S. Comparative efficacy of coconut oil-pulling therapy versus 0.2% chlorhexidine mouthrinse on dental plaque and gingival health: A clinicomicrobiological study. J Datta Meghe Inst Med Sci Univ [serial online] 2022 [cited 2023 Apr 1];17:847-52. Available from: http://www.journaldmims.com/text.asp?2022/17/4/847/369481
| Introduction|| |
Periodontitis is an inflammatory microbial disease caused by complex of microbes. Long-standing undisturbed plaque growth at the gingival margin and sequela of quantitative and qualitative changes of the subgingival microflora leads to loss of periodontal support. Periodontitis is a sequela of supragingival plaque accumulation. Prevention and control of periodontal disease must be based on the regular and complete removal of bacterial plaque. Various modes of mechanical and chemical means of plaque control exist. Among chemical plaque control, chlorhexidine (CHX) is considered the “Gold Standard” due to its superior antimicrobial properties. Its mechanism of action includes direct damage to the internal cytoplasmic membrane, being bacteriostatic at low dosages and bactericidal at high concentrations. Affinity to attach to a wide variety of substrates is known as substantivity, which allows this compound to attain efficacious antibacterial levels for prolonged period of time. CHX is discouraged because of its unpleasant taste and undesirable side effects such as tooth staining.
Conventionally, essential oils have also been used to cure many oral conditions. In the Indian ayurvedic system, oil pulling has been practiced for various oral and nonoral diseases. Oil pulling or oil swishing is a procedure or therapy that involves swishing oil in the mouth for oral and systemic health benefits. This therapy can be done using edible oils like sunflower or sesame oil. Oil-pulling therapy with sesame oil has been used extensively as a traditional Indian folk remedy for many years for multiple dental problems.
Coconut oil is an edible oil and is consumed as a part of the staple diet in many tropical countries. It has been proven to be therapeutic in many ways. In ayurvedic medicines, the oil, milk, cream, and water of coconut are all used to treat hair loss, burns, and heart problems. Coconut oil contains 92% saturated acids, chemical constituents in coconut fruit are lauric acid, myristic acid, caprylic acid and caproic acid, oleic acid, and linoleic acid. Approximately 50% of which is lauric acid. Human breast milk is the only other naturally occurring substance with such a high concentration of lauric acid. Oleic acid is an antioxidant that removes free radicals in the body and linoleic acid is a potent antioxidant, anticarcinogenic, a powerful immune system enhancer. Many oils have been investigated for their effectiveness as anti-plaque and anti-gingivitis agents. Very few studies have used coconut oil for this purpose.
Saliva is a perfect biological fluid to be explored for disease activity as it mirrors our body health. Intraoral transmission of pathogenic bacteria is mediated via saliva. Oral bacterial load is greatly influenced by the use of mouthwash. The possible effect of a mouthwash on bacterial load count in the mouth has received little or no attention in human studies.
To the best of our knowledge, none of the previous studies have correlated the antimicrobial effect of mouthwash on oral bacterial load. Thus, the present study was undertaken with the aim to investigate the efficacy of virgin coconut oil-pulling therapy versus 0.2% CHX mouthrinse and their effect on clinical parameters and total microbial load in salivary samples of periodontally healthy volunteers.
Source of data
The study was conducted in the Department of Periodontology, SGT Dental College, Hospital and Research Institute, SGT University. The study was initiated after obtaining approval from the review ethical board of SGT University. Informed written consent was obtained from all participants. A total of 30 periodontally healthy volunteers with the age range of 18–45 years were randomly divided into two groups:-Group 1: virgin coconut oil mouthrinse (Plant Lipids®, Cochin, India) and Group 2: 0.2% CHX mouthrinse (Clohex Plus®, Dr Reddy's, India).
Systemically healthy patients within the age ranging between 18 and 45 years with probing depth < 3 mm and clinical attachment loss <1 mm with at least 20 natural teeth in the permanent dentition and who were willing to comply with study protocol were included in the study. Patients on antibiotic and/or anti-inflammatory therapy 3 months before baseline examination, past history of tobacco chewing, smoking, allergic reaction to mouthrinses, or on orthodontic appliances were excluded from the study.
For achieving optimal gingival health, all the subjects of the study participated in a 7-day pretrial period. It comprised professional scaling and polishing. If oral hygiene maintenance of participant judged inadequate or insufficient, individual instructions were given on how to improve performance.
At baseline, demographic data and brief dental and medical history of the subject were recorded. Clinical parameters such as Plaque Index (PI), Gingival Index (GI), and Gingival Bleeding Index (GBI) were recorded for all the subjects. An unstimulated salivary sample was collected in a sterile calibrated bottle and sent for baseline examination of oral microbial load. To standardize the baseline gingival conditions, full-mouth scaling and polishing was performed with the help of a rubber cup and prophylactic paste on all the subjects. An elaborate explanation was provided to the subjects to stop all other oral hygiene aids. Subjects were asked to perform oil pulling in (Group 1) and 0.2% CHX rinse in (Group 2) in front of the instructor and were asked to continue for rest of the trial period in the same manner. The patients were asked to perform mouthrinsing/oil pulling twice daily: morning and evening.
Virgin coconut oil mouthrinse (Group 1)
Ten milliliter to fifteen milliliter of virgin coconut oil using a tea spoon, approximately 6 g or till the mouth is half filled. Subjects were asked to sip, suck, and pull the oil through the teeth. They were asked to lift their chin a bit, close eyes, and start swishing liquid from left to right, front to back and vice versa. They were instructed to concentrate and imagine liquid moving inside the mouth. Swishing was advised for approximately 8–10 min till the subject feels the fullness in the mouth. At the end, the oil was milky white, thin and frothy. The subject was asked to spit the swished oil.
Chlorhexidine mouthrinse (Group 2)
Subjects in the Group 2 were instructed to use 15 ml of undiluted CHX (0.2%) twice daily for 30 s, morning and evening after toothbrushing. Patients were instructed not to rinse with water or other mouthwashes, brush teeth, or eat immediately after using CHX. Patients were advised to expectorate CHX after rinsing.
According to the gingivitis model described by Loe et al., gingivitis progression was demonstrated at the 4th, 10th, and 21st days. Hence, the clinical parameters were recorded at baseline, day 10, day 21, and day 30, and the salivary samples were sent for microbiological analysis.
Each salivary sample was inoculated on agar plate by impregnating 0.001 ml of saliva with the help of calibrated standard loop. Incubation on agar plate was done at 37°C under anaerobic conditions for 24 h and was kept at room temperature for the next 24 h for better identification of colony characteristics [Figure 1] and [Figure 2]. A colony counter was used to count the number of colony-forming unit (CFU) on agar plates. The evaluation is done by examining the survival rate of microbes.
After the final recordings, a professional cleaning was performed, and subjects were asked to return to their routine habits of mechanical plaque control, gingivitis was treated if required.
| Results|| |
The present study was undertaken to evaluate the efficacy of coconut oil-pulling therapy and compare its effectiveness to 0.2% CHX mouthrinse on dental plaque and gingival health. All the 30 subjects completed the study. This study included a total of 30 patients (19 males and 11 females) aged between 18 and 45 years with a mean age of ± 30.5. Informed consent was obtained from all the study participants before starting the procedure. There were no untoward side effects reported.
The mean PI, GI, and GBI at baseline, day 10, day 21, and day 30 were compared between CHX and coconut oil using the unpaired t-test [Table 1], [Table 2], [Table 3]. The mean PI at day 10, day 21, and day 30 was significantly more among coconut oil than CHX group [Graph 1] and [Graph 2].
|Table 1: Efficacy of coconut oil and 0.2% chlorhexidine on plaque index at various time intervals|
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|Table 2: Efficacy of coconut oil and 0.2% chlorhexidine on gingival index at various time intervals|
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|Table 3: Efficacy of coconut oil and 0.2% chlorhexidine on gingival bleeding index at various time intervals|
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The mean CFU at baseline, day 10, day 21, and day 30 was compared between CHX and coconut oil using the unpaired t-test [Table 4]. The mean CFU at day 10, day 21, and day 30 was significantly more among coconut oil than the CHX group [Graph 3].
|Table 4: Efficacy of coconut oil and 0.2% chlorhexidine on colony-forming unit at various time intervals|
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| Discussion|| |
There has been an in surge of commercially available plaque control agents, including mechanical and chemical. Lately, adjunctive use of chemical plaque control agents along with mechanical agents is considered to be effective in completely eradicating dental plaque. The American Dental Association (ADA) council for scientific affairs has proposed a program for acceptance of plaque control agents. These include that the patients be evaluated in placebo control trials of 6 months or longer and demonstrate significantly improved gingival health compared with controls. To date, the ADA has accepted 2 agents for the treatment of gingivitis which include prescription solution of CHX digluconate oral rinse and nonprescription essential oil rinse.
CHX is considered to be the Gold Standard in chemical plaque control. It has been successfully used in periodontal infections. Löe et al. demonstrated that CHX mouthrinse controls supragingival plaque and reduces gingival inflammation. Other clinical studies have also indicated that subgingival irrigation with CHX can reduce plaque formation as well as gingival and periodontal inflammation. In a recent study, the ability of CHX to significantly reduce proteolytic degradation was demonstrated. This phenomenon was suggested to represent an additional beneficial effect provided by CHX. As an antimicrobial agent, CHX is effective against both Gram-positive and Gram-negative bacteria. Its antibacterial action is due to an increase in cellular membrane permeability followed by coagulation of the cytoplasmic macromolecules. It has also been shown that CHX can reduce the adherence of Porphyromonas gingivalis to epithelial cells. However, long-term usage of this mouthrinse is associated with few side effects. Compliance, altered taste sensation, and staining of the teeth are the most common problems with CHX administration.
Currently, ayurvedic medicine and its applications in dentistry especially periodontics per se are gaining popularity owing to their immense success rates with fewer side effects. Considering this fact, the present study aimed to employ a traditional way of mouthrinsing, i.e. oil-pulling therapy.
Kavala Graha or Gandoosha are procedures recommended for oral hygiene maintenance in Ayurveda. They are elaborately mentioned in the texts of Charaka Samhita and Sushrutha's Samhita. It is described as a procedure in which an individual takes a comfortable amount of oil/medicated oil and holds it or swishes it in the mouth. When the oil turns thin and milky white, it spits out without swallowing.
Oil pulling is similar to a mouthrinsing procedure in which a person swishes his/her mouth with a commonly used cooking oil for 3–10 min. Oil pulling is advantageous in that anyone can perform this using any ordinary cooking oil. Most of the Indian homes use refined sunflower oil, coconut oil, and groundnut oil for cooking. Therefore, this procedure can be performed at home easily with no hassle. When compared to the cost of mouthrinses (i.e. 30–40 rupees per 100 ml), the oil pulling can be very reasonable since cooking oil generally costs about 70–80 rupees per liter., In the context of the present-day busy lives, it is very hard to accept this procedure, unless and until more studies are carried out, and the benefits are proven repeatedly. According to ayurvedic literature, oil pulling has been known to be effective on some 30 systemic diseases.
Even though coconut oil is used for gargling among the people in coconut farming communities, no studies have been done on the benefits of oil pulling using coconut oil, till date. In the present study, virgin coconut oil was used for oil pulling. Coconut oil is a versatile oil that has many therapeutic benefits. It even exerts antimicrobial action owing to its unique fatty acid arrangement. Hierholzer and Kabara in 1982 discovered the antimicrobial effect of coconut oil.
The result of the present study showed that a demographic profile of participants has a normal distribution. The sample was homogenous, thus clearly indicated that age and sex have no correlation with oral bacterial counts. The present study evaluated both the clinical and microbiological parameters. PI, GI, and GBI were employed as these are the most commonly used indices for clinical trials. In the present study, oil-pulling therapy resulted in significant reductions in the mean scores of PI, GI, and GBI over the study period. Thus, coconut oil has a significant impact on gingival health. This is attributed to the versatile property of virgin coconut oil as an anti-inflammatory agent and it possesses antimicrobial properties. In the present study, CHX was found to be highly effective when PI, GI, and GBI scores were compared at day 10, day 21, and day 30. The reduction in mean PI score at day 10 was significant and at day 30 was highly significant (P < 0.001), i. e., CHX provided the best results which were in accordance with the study done by Brecx et al. When the comparison was done in both the groups at various intervals, the reduction in PI, GI, and GBI was highly significant when baseline levels were compared to 21st day and 30th day in both the groups. The results are in accordance with the study done by Peedikayil et al. which stated that the significant reduction in gingivitis can be attributed to decreased plaque accumulation and the anti-inflammatory, emollient effect of coconut oil.
On intergroup comparison between coconut oil and CHX group [Table 2], it was found that CHX was more effective in reducing PI, GI, and gingival bleeding scores. On day 21 and day 30, the mean difference for the CHX group was highly significant, thus stating that CHX has better antimicrobial properties than coconut oil, so showing a better reduction in clinical indices. The results are in accordance with the study done by Tritton and Armitage.
The antimicrobial potency of coconut oil was tested in the present study using oral bacterial count. Oil-pulling therapy led to a significant reduction in colony count of oral microorganism. The mean colony count at baseline for coconut oil was 169.87, at day 30 was 83.80, thus showing a statistically significant reduction (P < 0.05). This is because of the fact that hydrolysis of the virgin coconut oil produces 82% medium-chain fatty acids and monoglycerides which might explain its high antimicrobial activity. A similar study was done by Kumar et al. The comparison between coconut oil and CHX mouthwash was done and there was a considerable reduction in the colony count of microorganisms in both the study groups over the study period. Our results are in accordance with the studies conducted by Amith et al. and Asokan, in which PI scores and microbial aggregations were reduced following oil pulling. In our study, there was a considerable reduction in the colony count of microorganisms in both the study groups. On comparing intergrouP values, a statistically significant difference was obtained between the two groups, further suggesting CHX is more efficacious than coconut oil. As CHX is a membrane active substance, it acts on the inner cytoplasmic membrane of bacteria and causes damage to bacterial cells. The results obtained were in favor of earlier studies done by Grenier and Mcbain et al.,
In the present study, though the oil pulling gave good results with decreased microorganisms, however on comparing with CHX, it was not as effective, both clinically and microbiologically. Studies also have claimed that swishing with an oil triggers the enzymes and removes the microbial toxins out of the blood. Many studies also have mentioned contradictory statements in which oil pulling was not effective in removing toxins. The viscosity of the oil can also pose a challenge to bacterial adherence and co-aggregation.
It is often noticed that oral hygiene improves during clinical trials due to an effect known as the Hawthorne effect. It results due to the awareness of a subject that he is receiving some kind of therapy. This hypothesis can be applied for the present study in which the individuals (after initiating the oil pulling or CHX rinsing) might have changed their behavior positively. This is an assumption and could have been avoided by increasing the duration of the study.
Considering the population of developing country like India (approximately one-third), who lie below the poverty line, utilization of the results of such clinical trials is very much appropriate. The limitations of the present study include short duration of the study and smaller sample size. A control group could have been added. Further longitudinal studies with larger sample size, long duration, and comparison of effect of various oil can be done.
| Conclusion|| |
The present study concluded that oil pulling with virgin coconut oil has the ability to reduce plaque, gingivitis, and can be considered as an alternative to CHX. CHX was found to be the most effective in reducing plaque and gingivitis scores.
In the present study, plaque-induced gingivitis was significantly reduced as evident with clinical and microbiological parameters. Although both the study groups showed reductions in PI, GI, and GBI scores, higher reductions were seen in the CHX group.
It was observed that CHX and virgin coconut oil were effective against microorganisms, thus causes a reduction in CFU. The reduction in CFUs was more pronounced with CHX.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4]