|Year : 2019 | Volume
| Issue : 1 | Page : 40-44
Comparative evaluation of the effect of pomegranate peel extract and chlorhexidine 0.2% mouthwash on salivary pH in children between 6 and 8 years of age: An in vivo study
Nikita S Kadam, Sanket S Kunte, Alok R Patel, Preetam P Shah, Rahul R Lodaya, Laxmi S Lakade
Department of Pediatric and Preventive Dentistry, Bharati Vidyapeeth Deemed University Dental College and Hospital, Pune, Maharashtra, India
|Date of Web Publication||27-Feb-2019|
Dr. Nikita S Kadam
Department of Pediatric and Preventive Dentistry, Bharati Vidyapeeth Deemed University Dental College and Hospital, Pune, Maharashtra
Source of Support: None, Conflict of Interest: None
Background: Dental caries is chronic infectious disease affected by diet and cariogenic microorganisms. Streptococcus mutans is associated with the initiation of caries, and lactobacilli are associated with disease progression. Chlorhexidine is used as a gold standard mouthwash, but it has some side effects such as unpleasant taste and staining on long-term use. Hence, there is a need for alternative to chlorhexidine. Herbal mouthwashes are more excellent option to chemical mouthwashes for prolonged use. Pomegranate is one of them with antimicrobial, antioxidant, and anti-inflammatory properties. Aim: The aim of this study was to assess the effect of pomegranate peel extract and chlorhexidine mouthwash on salivary pH in 6–8 years of age children. Materials and Methods: Thirty patients between the age group of 6–8 years fulfilling the inclusion and exclusion criteria were selected. Children were divided into two groups randomly. Fifteen children were given chlorhexidine mouthwash and 15 were given pomegranate peel extract and asked to rinse for it 2 min. Saliva was collected before the mouth rinse, 10, 30, and 60 min after the mouthrinse. The pH of each collection was noted using pH meter. Statistical Analysis: Statistical analysis was done using the ANOVA test and unpaired t-test. Results: Both the mouthwashes show significant rise in the salivary pH in shortened time. Conclusion: Pomegranate peel extract mouth rinse can be used as an accompaniment to prevent caries and to maintain good oral hygiene in children.
Keywords: Chlorhexidine, pH, pomegranate peel extract, saliva
|How to cite this article:|
Kadam NS, Kunte SS, Patel AR, Shah PP, Lodaya RR, Lakade LS. Comparative evaluation of the effect of pomegranate peel extract and chlorhexidine 0.2% mouthwash on salivary pH in children between 6 and 8 years of age: An in vivo study. J Int Oral Health 2019;11:40-4
|How to cite this URL:|
Kadam NS, Kunte SS, Patel AR, Shah PP, Lodaya RR, Lakade LS. Comparative evaluation of the effect of pomegranate peel extract and chlorhexidine 0.2% mouthwash on salivary pH in children between 6 and 8 years of age: An in vivo study. J Int Oral Health [serial online] 2019 [cited 2019 Aug 21];11:40-4. Available from: http://www.jioh.org/text.asp?2019/11/1/40/253137
| Introduction|| |
Tooth surface is subjected to caries and various infections due to elements that favor the microbial growth. Dental caries can be managed by limiting tooth demineralization, by modifying the dietary habits, inhibiting or modifying oral microbial growth, altering the salivary pH, and by buffering capacity. The Streptococcus mutans and Lactobacillus species are the main causative factors of dental caries. They easily colonize over the tooth surface and synthesize extracellular polysaccharides from sucrose foods which cause initiation of acid production. Hence, caries prevention should be aimed at lowering the cariogenic bacteria.
A mouth rinse is advantageous home care measure to augment oral hygiene and to prevent dental caries. A variety of synthetic mouthwashes are available in the market to prevent dental caries. They can alter the plaque formation. Hence, they are effective to reduce dental caries. Chlorhexidine is one of the most popular mouth rinses. It is considered as a gold standard, but it has few disadvantages such as tooth staining, unpleasant taste, alters taste sensation, and increased calculus formation. Hence, there is a need for alternative to chlorhexidine.
Natural medicines have been a source of medical treatments for more than thousands of years, and they play a key role in the primary health care in underdeveloped and developing countries. Various herbal products such as Propolis, Emblica officinalis (also called as Amla), Ocimum sanctum L. (also known as Ocimum tenuiflorum, Tulsi), and Azadirachtaindica (commonly known as Neem) have shown significant precedence in reducing signs of gingival and periodontal inflammation. Similarly, they have the ability to prevent dental caries by inhibiting the virulence factors of S. mutans and Lactobacillus. The use of plants and their derivatives which have preventive and therapeutic effects could contribute to oral health.
Punica granatum Linn, mostly known as “pomegranate,” is considered as one of the ancient edible fruits. It is illustrative of infinity and well-being. It is extensively seen in the Himalayas in India to Iran, but it is cultivated since prehistoric times in Mediterranean region. In Ayurvedic medicine, it is considered as a “pharmacy unto itself.” The pomegranate shows anti-inflammatory, antioxidant, antimutagenic, and antimicrobial activity. Therefore, the aim of the present study is to assess the effect of pomegranate peel extract and chlorhexidine mouth rinse on salivary pH in children between 6 and 8 years of age.
| Materials and Methods|| |
The study protocol was approved by the research and Ethical Committee of Bharati Vidyapeeth Deemed University Dental College and Hospital (Registration Number ECR/328/Inst/MH/2016), Pune, Maharashtra, India.
To carry out this study, chlorhexidine 0.2% mouthwash, aqueous form of pomegranate peel extract [Figure 1], graduated polyethylene tube, and pH meter (Hanna Instruments. Model number: HI98100 checker plus) [Figure 2] were used.
|Figure 1: Chlorhexidine 0.2% mouthwash (left) and aqueous form of pomegranate peel extract (right)|
Click here to view
|Figure 2: pH meter (Hanna Instruments. Model number: HI98100 checker plus)|
Click here to view
Preparations of pomegranate peel extract
Peels of the pomegranate were dried in sunlight and overnight in a hot air oven at 60°C for 7 days. The dried peels were powdered. The obtained powder was used to make an aqueous extract in Soxhlet extractor. Sweeteners, flavoring agents, and preservatives were not added. The taste of the extract was acceptable. Fresh aqueous extract was used for the study every time.
Selection of study sample
For this study, 30 children coming to the Department of Pediatric and Preventive Dentistry, Bharati Vidyapeeth Deemed University Dental College and Hospital, Pune, Maharashtra, India, fulfilling the following inclusion and exclusion criteria were selected. In the study, children with caries, filled, and missing teeth between 6 and 8 years of age were included and children with abscess, draining sinus, cellulitis, or other conditions requiring pulp therapy or extraction were excluded. Furthermore, children with special health-care needs were not included in the study.
After the selection of children, a written informed consent informing the parents about the study was taken. Children were randomly divided into two groups.
- Group A had 15 children for 0.2% chlorhexidine mouth rinse and
- Group B had 15 children for pomegranate peel extract rinse.
Fifteen children of Group A were given 10 ml of chlorhexidine 0.2% mouthwash with 1:1 dilution in water and asked to rinse for 2 min. Saliva was collected in graduated polyethylene tube before the mouth rinse (collection 1), 10 min after the mouth rinse (collection 2), 30 min after the mouth rinse (collection 3), and 60 min after the mouth rinse (collection 4) using pH meter. pH of each salivary sample was recorded at four different intervals [Figure 3].
Similarly, in Group B, 15 children were given 3 ml of pomegranate peel extract rinse and asked to rinse for 2 min. A salivary sample was collected in graduated polyethylene tube before the mouth rinse, 10, 30, and 60 min after the mouth rinse [Figure 3].
Statistical analysis was carried out using ANOVA test for both the groups in terms of means and standard deviations. The comparison of salivary pH at different time intervals and P value was also analyzed.
| Results|| |
When the statistical analysis was carried out using ANOVA test for Group A and Group B, the comparison of salivary pH at different time intervals was noted [Table 1].
|Table 1: Comparison of salivary pH scores in terms of mean (standard deviation) at different time intervals in chlorhexidine and pomegranate peel extract group using repeated measures ANOVA test|
Click here to view
When the analysis was done using unpaired t-test, the comparison of different time intervals of both the groups was recorded [Table 2].
|Table 2: Comparison of salivary pH scores in terms of mean (standard deviation) at different time intervals among both the groups using unpaired t-test|
Click here to view
There was a significant increase in the pH of salivary sample in both Group A and Group B after the mouth rinses. Group B shows minimum increase in the salivary pH after the 10 and 30 min when compared to Group A, which is appreciable in [Graph 1].
| Discussion|| |
Microorganisms present over the tongue are responsible for the release of sulfur-containing compounds which cause halitosis. Saliva plays an important role in the maintenance of good oral health. A reduced saliva flow during sleep in healthy controls favors anaerobic bacteria breakdown giving rise to bad odor, this results from decreased salivary flow and decreased activity of tongue and cheek muscles during sleep, which promotes the growth of bacteria. Plaque is a known initiating factor in the development of gingivitis. Thus, plaque control is the mainspring of good oral hygiene practice. Salivary pH plays a major role in the formation of halitosis. Antibacterial components such as chlorhexidine, cetylpyridinium chloride, triclosan, essential oils, chlorine dioxide, zinc salts, benzalkonium chloride, hydrogen peroxide, and sodium bicarbonate have been used to maintain the salivary pH. Chlorhexidine is the most commonly used mouthwash to maintain good oral hygiene, but it has some side effects such as tooth staining on long-term use, unpleasant taste, augmented calculus formation, and also high cost. Hence, there is a need for new antimicrobial, anti-inflammatory, and antioxidant agents of plant origin which is safe, preventive, and economical as well.
In the present study, an aqueous form of pomegranate peel extract was used as it is rich in tannin, ellagitannins, and phenolic acids. These are considered to prevent gingivitis through various mechanisms, including the direct antioxidant activity, anti-inflammatory effects, antibacterial activity, and removal of plaque from the teeth. The pomegranate peel contains punicalagin, flavones, and tannins, including punicalin and punicafolin. Pomegranate has tannin which inhibits human salivary alpha-amylase, which catalyzes the hydrolysis of starch to oligosaccharides and binds to viridians streptococci and enamel, therefore providing a substrate for cariogenic microorganisms. Pomegranate peel extract fights with the dental plaque and reduces the calculus formation by discouraging the action of the microorganisms that initiate plaque formation. Pomegranate peel extract conquers the ability of microorganisms to adhere to the surface of the tooth.
Various in vitro studies have been carried out to evaluate the antibacterial efficacy of pomegranate peel extract. Lee et al. in 2005 stated that pomegranate extracts inhibit sucrose-digesting enzyme, and the organisms are responsible for plaque formation by competitive and noncompetitive inhibition. Polyphenolic flavonoids present in pomegranate are effective in maintaining good oral health and prevent the development of gingivitis. Another study by Hajifattahi et al., in 2016, evaluated the effect of hydroalcoholic extract of pomegranate on Streptococcus sanguis, S. mutans, Streptococcus salivarius, Streptococcus sobrinus, and Enterococcus faecalis. They stated that hydroalcoholic extract of P. granatum had a significant antibacterial effect on oral microorganisms. The maximum effect on S. mutans was seen. Vasconcelos et al. evaluated the antimicrobial efficacy of pomegranate phytotherapeutic gel and miconazole (Daktarin oral gel) against S. mutans, S. sanguis, and Streptococcus mitis strains. They concluded that pomegranate phytotherapeutic gel had greater efficiency in inhibiting microbial adherence than miconazole.
In this study, aqueous pomegranate peel shows increase in the salivary pH after 10 and 30 min of use, when compared with 0.2% chlorhexidine mouthwash. It increases salivary pH within short interval of time showing its antibacterial properties. Therefore, it can be easily replaced the synthetic mouthwashes to avoid its side effects.
In the study of Ahuja et al., pomegranate and chlorhexidine mouthwashes were compared. They concluded that pomegranate mouthwash is favorable in improving gingival status because it has keen styptic action, with adequate reduction in plaque.
The study carried out by Menezes et al. showed that after 1 min of mouth rinsing, more depletion in plaque was observed with pomegranate (84%) as compared with chlorhexidine (79%). In vivo study conducted by Abdollahzadeh et al. showed that pomegranate methanolic extract might be used to control common oral pathogens responsible, those are responsible for caries stomatitis and periodontal diseases. The antibacterial activity of pomegranate may be related to polyphenol structures because polyphenols may affect the bacterial cell wall, inhibit enzymes by oxidized agents, interact with proteins, and disturb coaggregation of microorganism.
In an Ohio State study, those who rinsed with pomegranate solution experienced a reduction in saliva total protein content which is normally higher among people with gingivitis and may correlate with plaque-forming bacterial content.
The study carried out by Umar et al. shows that pomegranate peel extract mouth rinse significantly lowered the salivary count of S. mutans as compared to the standard chlorhexidine mouthwash. Hence, according to their study, the herbal mouth rinse also increased the salivary pH significantly within a short-time interval of 10 min after the mouth rinse, thereby proving its potential as an anticariogenic agent. The present study shows the similar results. After the statistical analysis, pomegranate peel extract shows highly significant (P < 0.001) change in the salivary pH score at different time intervals similar to the chlorhexidine. This shows the anticariogenic efficacy of pomegranate peel extract.
Pomegranate will also lower saliva activities of alpha-glucosidase, an enzyme that breaks down sucrose, while it increased the activities of ceruloplasmin, an antioxidant enzyme. Thus, pomegranate may reveal anticariogenic effect as well, which may be utilized to prevent dental caries in individuals. The present study shows sudden increase in salivary pH after the use of pomegranate, which may exhibit anticariogenic effect. Therefore, pomegranate may manifest its anticariogenic potential as tested in vivo.
A limitation of our study was that we used pomegranate peel extract in a single concentration. However, further investigation is required to know the appropriate concentration of pomegranate peel extract as a mouthwash to use regularly.
| Conclusion|| |
The aqueous extract of pomegranate peel extract was as effective as a chlorhexidine mouth rinse. The future studies have to be focused at increasing the substantively of herbal mouthwashes so that they could be a future alternative to commercially available mouthwashes such as 0.2% chlorhexidine with great antimicrobial, cost-effective, and preventive strategies for dental caries.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Velmurugan A, Madhubala MM, Bhavani S, Satheesh Kumar KS, Sathyanarayana SS, Gurucharan N, et al.
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.
] [Full text]
Khirtika SG, Sindhu R, Muralidharan NP. Comparative evaluation of antimicrobial efficacy of 0.2% chlorhexidine, 2% iodine and homemade mouth rinse as an anti-caries agent- a clinical study. J Pharm Sci Res 2017;9:2114-6.
Eley BM. Antibacterial agents in the control of supragingival plaque – A review. Br Dent J 1999;186:286-96.
Gadiyar A, Ankola AV, Rajpurohit L. Evaluation of the antimicrobial activity of Ocimum sanctum
L. (Tulsi) extract against Streptococcus mutans
acidophilus – An in vitro
study. Int J Health Sci Res 2017;7:224-8.
Subramaniam P, Dwivedi S, Uma E, Girish Babu KL. Effect of pomegranate and Aloe vera
extract on Streptococcus mutans
: An in vitro
study. Dent Hypotheses 2012;3:99-105. [Full text]
Deswal H, Singh Y, Grover HS, Bhardwaj A, Verma S. Pomegranate as a curative therapy in medical and dental sciences: A review. Innov J Med Sci 2016;4:15-8.
Jurenka JS. Therapeutic applications of pomegranate (Punica granatum
L.): A review. Altern Med Rev 2008;13:128-44.
Bhandari PR. Pomegranate (Punica granatum
L). Ancient seeds for modern cure? Review of potential therapeutic applications. Int J Nutr Pharmacol Neurol Dis 2012;2:171-84.
Tolentino Ede S, Chinellato LE, Tarzia O. Saliva and tongue coating pH before and after use of mouthwashes and relationship with parameters of halitosis. J Appl Oral Sci 2011;19:90-4.
Malhotra R, Grover V, Kapoor A, Saxena D. Comparison of the effectiveness of a commercially available herbal mouthrinse with chlorhexidine gluconate at the clinical and patient level. J Indian Soc Periodontol 2011;15:349-52.
] [Full text]
BenSaad LA, Kim KH, Quah CC, Kim WR, Shahimi M. Anti-inflammatory potential of ellagic acid, gallic acid and punicalagin A&B isolated from Punica granatum
. BMC Complement Altern Med 2017;17:47.
Umar D, Dilshad B, Farhan M, Ali A, Baroudi K. The effect of pomegranate mouthrinse on Streptococcus mutans
count and salivary pH: An in vivo
study. J Adv Pharm Technol Res 2016;7:13-6.
] [Full text]
Ramesh KS, Shamin SF. Role of pomegranate in preventive dentistry. Int J Res Ayurveda Pharm 2012;3:648-9.
Lee CJ, Chen LG, Liang WL, Wanga CC. Anti-inflammatory effects of Punica granatum
Linne in vitro
and in vivo
. Food Chem 2010;118:315-22.
Hajifattahi F, Moravej-Salehi E, Taheri M, Mahboubi A, Kamalinejad M. Antibacterial effect of hydroalcoholic extract of Punica granatum
Linn. petal on common oral microorganisms. Int J Biomater 2016;1:6.
Vasconcelos LC, Sampaio FC, Sampaio MC, Pereira Mdo S, Higino JS, Peixoto MH, et al.
Minimum inhibitory concentration of adherence of Punica granatum
Linn (pomegranate) gel against S. mutans, S. mitis
and C. albicans
. Braz Dent J 2006;17:223-7.
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. [Full text]
Abdollahzadeh SH, Mashouf RY, Mogahaddam MH, Roozbahani N, Vahedi M. Antibacterial and antifungal activities of Punica granatum
extract against oral pathogens. J Dent Tehran Univ Med Sci 2011;8:1-6.
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2]