Journal of International Oral Health

REVIEW ARTICLE
Year
: 2018  |  Volume : 10  |  Issue : 6  |  Page : 267--271

Triphala and its efficacy in treating gingival diseases: A systematic review


D Prabu, R Sindhu 
 Department of Public Health Dentistry, SRM Dental College, Chennai, Tamil Nadu, India

Correspondence Address:
Dr. D Prabu
Department of Public Health Dentistry, SRM Dental College, Ramapuram, Chennai - 600 089, Tamil Nadu
India

Abstract

Aims and Objectives: The aim of the study is to assess the efficacy of triphala in treating gingival diseases. Materials and Methods: A literature review was performed using Medline, PubMed, Wiley, ScienceDirect, Cochrane Central Register of Controlled Trials (CENTRAL), Scopus, and Grey literature using MeSH terms - Triphala, gingivitis, and dentistry. Of a total of 251 titles appeared from various sources, 243 articles were screened and 27 were related to the research question. This review was reported according to the preferred reporting items for systematic reviews and meta-analyses guidelines. Results: Seven trials were included and they were all compared with chlorhexidine. Among the seven trials, five found statistically significant differences favoring the effectiveness of triphala mouthwash. No meta-analysis was performed due to the clinical heterogeneity and differences in the reporting of data among the included studies. Conclusion: In the available literature, the multiple beneficial effects of triphala was found to be effective in treating gingival diseases as well as equally effective to the gold standard mouthwash chlorhexidine in improving gingival health.



How to cite this article:
Prabu D, Sindhu R. Triphala and its efficacy in treating gingival diseases: A systematic review.J Int Oral Health 2018;10:267-271


How to cite this URL:
Prabu D, Sindhu R. Triphala and its efficacy in treating gingival diseases: A systematic review. J Int Oral Health [serial online] 2018 [cited 2019 Mar 20 ];10:267-271
Available from: http://www.jioh.org/text.asp?2018/10/6/267/248436


Full Text

 Introduction



Ayurveda is an ancient system of medicine with an Indian origin, which is an alternative medicine that offers medications using herbs. In recent times, various clinical trials have been conducted using Ayurvedic medicines against the gold standard allopathic medicines. Oral health has a considerable effect on a person's general health, and Ayurveda has numerous effective medicines that are used to improve oral health. The natural phytochemicals present in the Ayurvedic medicines acts as an effective therapeutic alternative to allopathic antibiotics.[1]

Gingivitis is one of the commonly prevalent oral diseases worldwide which is caused by the bacterial biofilm adhering to the teeth surfaces. There are a total of 15 plant herbs in Ayurvedic medicine that are used effectively in dentistry.[2] Triphala is one of the effective Ayurvedic herbal formulations consists of Terminalia bellirica Roxb (Bibhitaki), Terminalia chebula Retz (Haritaki), and Emblica Officinalis Gaertn (Amalaki). T. bellirica Roxb and T. chebula Retz have a warm energy, while Emblica Officinalis possess a cooling energy. Triphala has equal parts of these three herbs, which has a balanced internal cleansing and detoxifying formula.

In Ayurvedic medicine, it is commonly known as a good purgative and an essential rasayana. Charaka and Sushruta Samhita has described the formulation of this herbal supplement in the traditional Indian text.[3] It has a broad spectrum of activity such as antimicrobial, anticaries, and anti-collagenase activities. According to Sushruta Samhita, the herb triphala can be used as an herbal mouthrinse in dental diseases.[4]

If such Ayurvedic preparation like triphala reaches as a product in the market with excellent beneficial effect, it would prove to be economical and path-breaking in the field of public health.

Objective

To evaluate the efficacy of triphala on gingivitis

 Materials and Methods



Inclusion criteria

Original articlesIn vivo studiesArticles on the efficacy of triphala on gingivitis.

Exclusion criteria

Review articlesArticles without open accessStudies done on other than gingival diseasesStudies done in a combination of triphala with other herbs.

Search strategy

Published literatures on recent advancements in assessing the efficacy of triphala on gingival-related diseases which includes original articles and research papers in databases such as PubMed Central, ScienceDirect, and Cochrane Central Register of Controlled Trials (CENTRAL) were taken into the study for review from August to September 2018. A literature search to collect relevant data was performed using the MeSH terms Triphala, gingivitis, and dentistry. A total of 251 abstracts appeared with this combination. Of these, 27 articles were research related. For each retraction, a total of 7 articles were retrieved for review.

Search engine

MedlinePubMedWileyScienceDirectCochrane Central Register of Controlled Trials (CENTRAL)ScopusGray literature.

 Results



The search yielded 251 records and 27 full-text articles were independently assessed. Among these 27 articles, 7 articles were included for the review. [Figure 1] shows the flow diagram of the reports that were identified, duplicates removed, screened, excluded, assessed for eligibility, and included in the review.{Figure 1}

[Table 1] shows the characteristics of the interventions in the included studies. In all the seven studies, triphala mouthwash was compared with chlorhexidine and a control group; but the studies differed individually regarding the sample size, age of the population, and duration of the intervention. Three of the trials were performed among school children;[6],[8],[9] two trials were among adult population from the outpatient department of various hospitals;[5],[10] one trial was performed among 18–24 years female undergraduate students[7] and the age was not mentioned in one of the trials.[11]{Table 1}

[Table 2] shows the outcome data of gingivitis in the included studies. There was a progressive decrease in the plaque and gingival scores in triphala group and chlorhexidine group compared to the control group from baseline till the end of the intervention period in all the studies, with a statistically significant P value. [Table 3] shows the risk of bias in the included studies. None of the studies had low risk of bias, and most of the domains had an unclear risk of bias.{Table 2}{Table 3}

 Discussion



In recent times, triphala is being used in dentistry, particularly in improving gingival health. Our search yielded five studies in favor of the effectiveness of triphala which was found to equal with the gold standard chlorhexidine mouthrinse; however, two of the studies showed no significant differences in the effectiveness. The antimicrobial and antioxidant effect of triphala in inhibiting Streptococcusmutans at concentrations as low as 50 μg/ml has been proven in vitro. The tannic acid present in triphala plays the role of anti-plaque effect, which gets adsorbed on the surfaces of the bacterial cell and results in denaturation of protein and eventually cell death.[12]

Pradeep et al.[5] reported a significant difference with respect to reduction in plaque index (PI), Gingival index (GI), simplified oral hygiene index, and anti-microbiological counts in both triphala and chlorhexidine groups. Although there was no significant difference noticed between the groups. The study was randomized with proper blinding and found to be the most reliable study among the included studies. Chainani et al.[6] reported a significant reduction in PI and GI scores in chlorhexidine and triphala groups compared to placebo group with a P < 0.001. Baratakke et al.[7] reported a significant reduction in plaque and gingival scores in triphala and chlorhexidine groups as compared to control group with a P < 0.001.

Bajaj and Tandon[8] reported a significant progressive decrease in plaque scores from baseline till the end of 9 months in both triphala and chlorhexidine groups, whereas increase in plaque scores in negative control group. Bhattacharjee et al.[9] reported that significant decrease in gingival and plaque scores in both chlorhexidine and triphala groups at follow-up than baseline with a P < 0.001. However, the percentage difference in the mean plaque index was significantly higher in the chlorhexidine group compared to the triphala group with a P < 0.048.

Desai et al.[10] reported a significant reduction in periodontal indices in chlorhexidine and triphala groups who received scaling and root planing along with mouthwashes compared to a control group that received only scaling and root planing. Naiktari et al.[11] reported a significant difference in PI and GI in both chlorhexidine and triphala groups compared to the control group with distilled water; a significant difference in PI and GI was reported within chlorhexidine and triphala groups with a P < 0.05.

Two of the studies had a high risk of bias with no blinding of the participants and no specific strategies were carried out to prevent selection bias; hence found to be less reliable. Among the seven included studies from this systematic review, triphala is found to be equally effective to the gold standard mouthwash “Chlorhexidine” in reducing the plaque scores without acquiring disadvantage of staining of teeth. In all the studies, triphala is compared with chlorhexidine and a placebo group; significant difference is observed with plaque and gingival index scores among triphala and chlorhexidine groups. In one of the seven studies, conflicting result is obtained with a percentage difference in the mean plaque index being significantly higher in the chlorhexidine group compared to the triphala group.[9]

Thus, it is relevant that triphala is equally effective to chlorhexidine in improving the oral health. The multiple beneficial effects of triphala as antimicrobial agent in reducing the dental plaque are an effective as well as an economic alternative. Triphala could be used as a short-term regimen with equal effectiveness. There is no conclusive evidence that triphala is the most effective regimen in treating gingivitis. For future recommendations of these agents to be used, high-quality trials need to be conducted.

The limitations of this review include; from a total of 243 articles screened, 27 articles were eligible for the study, but only 7 of the articles were based on clinical trials that were taken for this review; they all varied according to the age of the population, sample size and duration of the intervention.

 Conclusion



There is strong conclusive evidence that triphala can be used as an anti-plaque herbal medicine in improving gingival health and also as an alternative to the commercially available mouth rinse.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1Singh J, Kumar A, Budhiraja S, Hooda A. Ethnomedicine: Use in dental caries. Braz J Oral Sci 2007;6:21.
2Gupta R, Ingle NA, Kaur N, Yadav P, Ingle E, Charania Z, et al. Ayurveda in dentistry: A Review. J Int Oral Health 2015;7:141-3.
3Chouhan B. Triphala: A comprehensive ayurvedic review. Int J Res Ayurveda Pharm 2008;4:612-7.
4Nair SK, Shivaprasad BM. Triphala: A miracle herb in the field of dentistry. J Dent Health Oral Disord Ther 2018;9:00320.
5Pradeep AR, Suke DK, Martande SS, Singh SP, Nagpal K, Naik SB, et al. Triphala, a new herbal mouthwash for the treatment of gingivitis: A Randomized controlled clinical trial. J Periodontol 2016;87:1352-9.
6Chainani SH, Siddana S, Reddy C, Manjunathappa TH, Manjunath M, Rudraswamy S, et al. Antiplaque and antigingivitis efficacy of triphala and chlorhexidine mouthrinse among schoolchildren – A cross-over, double-blind, randomised controlled trial. Oral Health Prev Dent 2014;12:209-17.
7Baratakke SU, Raju R, Kadanakuppe S, Savanur NR, Gubbihal R, Kousalaya PS, et al. Efficacy of triphala extract and chlorhexidine mouth rinse against plaque accumulation and gingival inflammation among female undergraduates: A randomized controlled trial. Indian J Dent Res 2017;28:49-54.
8Bajaj N, Tandon S. The effect of triphala and chlorhexidine mouthwash on dental plaque, gingival inflammation, and microbial growth. Int J Ayurveda Res 2011;2:29-36.
9Bhattacharjee R, Nekkanti S, Kumar NG, Kapuria K, Acharya S, Pentapati KC, et al. Efficacy of triphala mouth rinse (aqueous extracts) on dental plaque and gingivitis in children. J Investig Clin Dent 2014;6:206-10.
10Desai A, Anil M, Debnath S. A clinical trial to evaluate the effects of triphala as a mouthwash in comparison with chlorhexidine in chronic generalized periodontitis patient. Indian J Dent Adv 2010;2:243-7.
11Naiktari RS, Gaonkar P, Gurav AN, Khiste SV. A randomized clinical trial to evaluate and compare the efficacy of triphala mouthwash with 0.2% chlorhexidine in hospitalized patients with periodontal diseases. J Periodontal Implant Sci 2014;44:134-40.
12Jagdish L, Anand Kumar VK, Kaviyarasan V. Effect of triphala on dental biofilm. Indian J Sci Technol 2009;2:30-3.