Effectiveness of toothpaste with herbal ingredients in a group of adults with gingivitis in Russia

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Effectiveness of toothpaste with herbal ingredients in a group of adults with gingivitis in Russia

Kuzmina E.M.

DDS, PhD, Professor Department of Preventive Dentistry Moscow State University of Medicine and Dentistry named after A.I.Evdokimov

Lapatina A.V.

PhD, Assistant professor Department of Preventive Dentistry Moscow State University of Medicine and Dentistry named after A.I.Evdokimov

Abstract

anti-inflammatory plaque toothpaste

Prevention and treatment of early signs of periodontal disease should be based on careful plaque control and use oral hygiene products with anti-inflammatory and antimicrobial effect. The aim of the study was to evaluate effectiveness of toothpaste with herbal ingredients [One Drop Only Toothpaste Concentrate (“One Drop Only GmbH”, Germany)] to inhibit dental plaque formation, reduce gingival inflammation in adults and reveal its influence on biofilm. Methods: 54 adult volunteers (aged 20-35 years-old) with chronic marginal gingivitis took part in the study. During 8 weeks patients use test toothpaste twice a day. Values of Patient Hygiene Performance Index (PHP), Aproximal Plaque Index (API), Gingival Index (GI), Sulcular Bleeding Index (SBI) were estimated at baseline, after 3, 6 and 8 weeks. Evaluation of pathogenic and resident specimens in gingival sulcus biofilm (by PCR and cultural bacteriological examination) was conducted at baseline and after 8 weeks. Results: After 8 weeks significant decrease of dental plaque accumulation was observed both on smooth tooth (19.3%, p<0.001) surfaces and approximal surfaces (14.5%, p<0.05). Reduction of gingival inflammation degree (according to GI Index criteria) was 56.3%, gingival bleeding (according to SBI Index criteria) - 69.8% (p<0.001). Perio-pathogen specimens such as Aggregatibacter actinomycetemcommitans, Tannerella forsythia, Treponema denticola and Fusobacte- rium nucleatum were not found in biofilm samples during final microbiological examination. Active ingredients of test toothpaste did not caused adverse changes of normal microflora. Conclusions: Daily use of toothpaste with herbal ingredients provided significant improvement of oral hygiene and periodontal status in adults with gingivitis.

Key words: Gingivitis, Toothpaste, Herbal Ingredients, Oral Hygiene, Biofilm

Introduction

Periodontal diseases are one of the main oral health problems among Russian adults. According the results of second National Oral Health Survey (2008) signs of periodontal inflammation was obsersed in 81% of 35-44 year-olds. Most of the surveyed adults had early stage of inflammation, prevalence of advanced stage of inflammation (periodontal pockets) was 17% [17].

Well-known that bacteria in dental plaque are one of the main factors causing gingival inflammation [2]. Therefore prevention and treatment of periodontal disease should be based on careful plaque control and use oral hygiene products with anti-inflammatory and antimicrobial action [6].

Numerous studies have shown high bactericidal and bacteriostatic effect of antiseptics and their ability to inhibit dental plaque formation. But risk of oral dysbiosis and other side effects limits the long-term application of antibacterial toothpastes and mouthwashes [9].

An alternative is the use of oral hygiene products containing herbal ingredients that have different treatment effects: anti-inflammatory, antimicrobial, hemostatic, etc. Also they don't cause changes in normal microflora and biofilm sensitivity to antimicrobial drugs.

The aim of the clinical and laboratory study was to evaluate effectiveness One Drop Only Toothpaste Concentrate with herbal ingredients to inhibit dental plaque formation and reduce gingival inflammation and bleeding in adults with gingivitis as well as to reveal its influence on biofilm.

Methods

Clinical investigation was carried out by calibrated dentists in Preventive Dentistry Department of Moscow State University of Medicine & Dentistry. The study of biofilm composition was performed by staff of Microbiology Department.

In total, 54 volunteers aged 20-35 years old (mean age 26.9±1.2) took part in the study. Each patient was signed the informed consent to participation in the study.

The inclusion criteria were poor oral hygiene and signs of gingival inflammation corresponding chronic marginal gingivitis.

The criteria of non-inclusion were advanced periodontal inflammation; taking of antibiotics or antiseptics less then one month before the study beginning; hypersensitivity to the test toothpaste ingredients; pregnancy and nursing; pregnancy and nursing.

All patients have been instructed to brush their teeth twice a day during 3 minutes with soft toothbrush and test toothpaste containing herbal ingredients (Tea Tree Oil, Mentha Piperita Oil, Bisabolol) and fluoride (1450 ppm), using pea-size amount for single toothbrushing. After toothbrushing patients rinsed a mouth with water during 30 seconds.

Methods of oral examination

Oral examination which was performed at the beginning of the study (baseline), after 3, 6 and 8 weeks included the following methods:

estimation of dental plaque accumulation on smooth tooth surfaces by Patient Hygiene Performance Index, PHP [13] and on aproximal tooth surfaces by Aproximal Plaque Index, API [7];

evaluation of gingival inflammation degree by Gingival Index, GI [8];

revealing of gingival sulcus bleeding by Sulcular Bleeding Index, SBI [11].

Methods of microbiological study

For microbiological study 8 patients were randomly selected. The sampling was carried out before meals and toothbrushing during baseline examination and after 8 weeks. In each patient one site in most inflamed area of periodontal tissues was chosen and cleaned with a sterile cotton wool tampon. Supragingival plaque was removed using sterile curette. Then absorbent paper point (standard № 30) was led to gingival sulcus excluding contact with saliva and tooth enamel. Biofilm samples were placed to the test tube, containing 500 mkl of 0,9% NaCl (for PCR) or 500 mkl of Aim's transport medium (for cultural bacteriological examination) and delivered to microbiological laboratory.

Study of biofilm composition included:

identification of perio-pathogens DNA (Aggre- gatibacter actinomycetemcommitans, Tannerella for- sithia, Prevotella intermedia, Porphyromonas gingi- valis, Treponema denticola) by multiplex polymerase chain reaction (PCR);

cultural bacteriological examination using anaerobic cultivation technique for determination of microbial counts of pathogenic and resident specimens.

Statistical analysis

Data of the study were entered into statistical software and Student's t-test was used to compare the difference of the mean values. Results were tested for significance at the p<0.05 level.

Results

All the volunteers participated in the clinical study till the end. During questionnaire all of them evaluated taste of toothpaste as good and also noted fresh breath for a long time after toothbrushing. There were no local irritation or allergic reaction associated with toothpaste application.

Evaluation of oral hygiene level

Baseline examination revealed that oral hygiene level of all participants was unsatisfactory according to PHP and API indices criteria.

Dynamics of plaque indices mean values is shown in Figure 1.

Fig. 1.

Decrease of dental plaque accumulation on smooth (PHP) and aproximal (API) tooth surfaces during 8 weeks

After 3 weeks significant reduction of dental plaque on smooth tooth surfaces was observed (p<0.01). Decrease of dental plaque accumulation on aproximal tooth surfaces was not significant compared to baseline after 3 and 6 weeks (p>0.05).

However, at final examination reduction of dental plaque was significant both on smooth (p<0.001) and aproximal (p<0.05) tooth surfaces. Mean value of PHP and API after 8 weeks decreased by 19.3% and 14.5% respectively compared to baseline (Table 1).

anti-inflammatory plaque toothpaste

Table 1 Dynamics of plaque indices values

* Number of examination

Evaluation of periodontal status

At baseline all subjects have signs of gingival inflammation: bleeding by probing, hyperemia and swelling of gingival margin.

Dynamics of periodontal indices mean values is shown in Figure 2.

Fig. 2. Decrease of gingival inflammation (GI) and gingival bleeding (SBI) during 8 weeks

After 3 weeks mean values of GI and SBI indices were significantly decrease compared to baseline (p<0.001). During following examination the same tendency was observed: differences between 3 and 6 weeks data were significant (p<0.05).

After 8 weeks gingival inflammation degree according to GI Index criteria was 56.3% lower compared with baseline data. Reduction of gingival bleeding according to SBI Index criteria was 69.8%. Differences of baseline and final values of GI and SBI indices were significantly (p<0.001) (Table 2).

Table 2Dynamics of periodontal indices values

* Number of examination

Results of the microbiological study

At baseline examination of biofilm samples composition most (86%) of patients had perio-pathogens in concentration from 4,0 till 6,0 lg CFU. More frequently (in 38% of cases) were detected Aggregatibacter acti- nomycetemcommitans, Tannerella forsythia and Treponema denticola. Frequency of Porhyromonas gingi- valis and Fusobacterium nucleatum detection was 25%, Prevotella intermedia - 13%.

Among conditional pathogenic specimens Enterococcus spp. was detected in 38% of cases and Staphylococcus epidermidis - in the single case. These bacteria are resident, but in high concentration can support a periodontal inflammation.

Stabilizing resident specimens Streptococcus sanguinis and Streptococcus salivarius were detected in 100% and 50% of cases respectively.

After daily toothbrushing with test toothpaste during 8 weeks most perio-pathogens were not found in biofilm samples (Figure 3). In the single case Prevotella intermedia was detected, but its concentration was half that of the baseline examination. Also significant decrease of Enterococcus spp. concentration (from 6.0±0.4 to 4.3±0.4 lg CFU, p<0.05) was observed. Staphylococcus epidermidis was not detected during final microbiological study.

Fig. 3. Frequency of perio-pathogens detection (%) in gingival sulcus biofilm

Resident specimen Streptococcus sanguinis was still identified in 100% of cases, but its concentration non-significantly decreased from 5.9±0.8 lg CFU till 4.4±0.6 lg CFU (p>0.05). Frequency of Streptococcus salivarius detection increased from 50% to 75%, its concentration did not change (Figure 4, Table 3).

Fig. 4. Frequency of resident specimens detection (%) in gingival sulcus biofilm

Table 3Frequency of detection (%) and concentration (lg CFU) of perio-pathogen and resident specimens in gingival sulcus biofilm

Discussion

Results of the study demonstrated benefits of toothpaste with herbal ingredients for improvement of oral hygiene and decrease of gingival inflammation in adults.

In the framework of this study daily application of test toothpaste promoted significant decrease of plaque accumulation and increased effectiveness of cleaning smooth tooth surfaces (on 19.3%) and aproximal surfaces (on 14.5%). In other studies, there is no consensus about the ability of toothpaste with herbal ingredients to reduce plaque formation [5,12,14,16]. On our opinion it is very important to control patient's oral hygiene skills during each visiting a dentist or dental hygienist. In this case effectiveness of plaque removal will be the highest.

The most considerable was anti-inflammatory effect of the test toothpaste. Reduction of gingival inflammation degree was 56.3% and decrease of gingival bleeding - 69.8%. Significant differences of GI and SBI values (p<0.001) were observed after 3 weeks of toothpaste application. Results of other clinical studies confirmed the effectiveness of toothpaste with herbal ingredients in control of gingivitis [3,4,10].

Probably, high antigingivitis activity is due to the antimicrobial properties of herbal essential oils. After 8 weeks significant reduction of perio-pathogens detection and their concentration were observed. Most periopathogen specimens as Aggregatibacter actinomy- cetemcommitans, Tannerella forsythia, Treponema denticola and Fusobacterium nucleatum were not found in biofilm samples during final microbiological examination.

Results of in-vitro study showed that herbal toothpaste have comparable immediate and ongoing antibacterial effect as chlorhexidine. Natural antimicrobials and chlorhexidine absorb in oral biofilms which contributes to their substantive action [15]. At the same time, the test toothpaste do not cause side-effects associated with chlorhexidine, such as extrinsic stains on the teeth, dental calculus formation, changes in taste perception [1].

It is also important that active ingredients of the test toothpaste did not caused adverse changes of normal microflora. Therefore, toothpaste with herbal ingredients can be daily used during long-term period. Because of concentrated composition this toothpaste is economical and pea-size amount enough for single toothbrushing.

Conclusions

Daily application of toothpaste with herbal ingredients during 8 weeks provided significant reduction of dental plaque accumulation and decrease of periodontal inflammation in adults with gingivitis. Active components of toothpaste showed antibacterial effect against perio-pathogenes without negative influence on the normal microflora. Therefore toothpaste with herbal ingredients can be recommended to use twice a day for improvement of oral hygiene, prevention and treatment of gingival inflammation.

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