Comparative Evaluation of the Effect of Alum and Herbal Mouthrinses on Plaque Inhibition in Children: A Randomized Clinical Trial

INTRODUCTION

Dental plaque is a biofilm seen on oral surfaces which is considered as an etiologic factor for dental decay and gum disease. The formation of an acquired pellicle is the first stage in bacterial plaque formation. The source of energy for certain bacteria in the oral cavity is from the enamel pellicle of salivary constitutes. Dietary starch hydrolysis is by alpha-amylase, a component of acquired enamel pellicle derived from saliva provides additional glucose for metabolism by plaque microorganisms in close proximity to the tooth surface.^1–3

Lactic, formic, and acetic acid are produced from fermentable carbohydrates which coincide with a pH drop in plaque that leads to tooth demineralization. This leads to further growth of microorganisms contributing to the cariogenicity of the dental plaque.^2,3

Plaque preventive measures like mechanical or chemical approaches can be used in combination with this. The various vehicles for delivery of chemical agents with anti-plaque are toothpastes, mouthrinses, gels, varnishes, chewing gum, spray, irrigators, etc. Antimicrobial agents may aid in protection by reducing plaque formation on the tooth surface, by inhibiting only those bacteria directly associated with oral diseases, or by inhibiting acid production or protease activity.^4–6

Traditional mechanical methods have been proved inadequate for controlling plaque and caries, so endeavor on latest chemotherapeutic agents for preventing plaque-induced oral disease. Mouthrinses have been developed to deliver broadly the same functional benefits as toothpaste. Mouthwash is defined as a deodorizing antiseptic non-sterile aqueous solution, removes food particles, reduces bad breath, and provides a pleasant taste. Mouthwashes can reach difficult to clean areas such as interproximal surfaces and can also reduce the growth of biofilms on soft tissues.^7–9 Different types of mouthwashes are used for preventing dental caries, oral malodor, gingival and periodontal diseases like chlorhexidine digluconate (antiseptic), stannous fluoride (anticariogenic), essential oils (antimicrobial), triclosan (antiseptic), sanguinarine (herbal extracts), cosmetic and cetylpyridinium chloride mouthwash.¹⁰

Various metal salts, polyvalent cations like tin, zinc, and aluminum (Al) as potassium sulfate salt, alum have plaque inhibitory activity so used in mouthwashes. Rinsing with a mixture of alum, salt, and vinegar for oral health was advocated by Hippocrates in ancient times.¹¹ Alum mouthwashes used for its properties like astringent, anti-plaque, anti-gingivitis, antimicrobial, antiseptic, anti-calculus, decreasing dentinal hypersensitivity, prevention of halitosis, reduction of enamel dissolution, and symbiotic activity with fluoride.^12–14 However, chemical mouthwash has many side effects, such as extrinsic staining of the teeth, temporary taste alteration, supragingival calculus formation. This has restricted its usage in children.¹⁵ Hence, attention is now turning to the use of natural antimicrobial compounds (herbal extracts). The combination of herbal extracts leads to the synergistic reduction of both dental plaque and gingival bleeding.⁹

Natural herbs like triphala, tulsipatra, neem, clove oil, and many more are used against various oral health problems.^5,16 Hi-ora is a liquid that acts as an oral antiseptic, prevents gum and tooth disease, prevents bad breath and mouth ulcers, and also helps in gum tightening. It does not contain alcohol and sugar and is prepared with active ingredients like Pilu (Salvadora persica), Bibhitaka (Terminalia bellerica), Nagavalli (Piper betle), Gandhapura taila (Gaultheria fragrantissima), Ela (Elettaria cardamomum), Peppermint satva (Mentha spp), and Yavanisatva (Trachyspermum ammi). Hi-ora has an antimicrobial, anti-plaque, antiseptic, analgesic effect, reduces halitosis, inhibits the growth of periodontal and cariogenic pathogens. Herbal mouthwashes are now considered as an alternative and metallic compounds have been used in the past for their antimicrobial properties.¹⁷

However, very few studies have assessed the effect of alum mouthwash and herbal mouthwash on plaque inhibition. Hence, this study aimed to evaluate the effect of the alum mouthwash on plaque inhibition among 9–12 years old children.

MATERIALS AND METHODS

Double-blind randomized three parallel groups were taken among 9–12 years old children. Consent was obtained from the local ethical committee and permission was sought from the concerned study participants. Survey design is given in Flowchart 1. The study sample consists of 9–12 years old 60 healthy children with a mean age of 10 years (Fig. 1). A total of 100 children were screened, of which 60 children were randomly selected which satisfied the inclusion and exclusion criteria.

They were divided into 3 groups, 20 in each group: group I: alum mouthwash (0.02 M) 0.885% hydrated aluminum potassium sulfate in distilled water at pH of 3–3.6. Group II: normal saline rinse (0.9%). Group III: herbal (Hi-ora) mouthwash. The plaque status of the children was recorded using plaque indices. The duration of the study was 1 month; which was divided into three phases: 1st, 15th, and 30th day.

DENTAL EXAMINATION PROCEDURE

Clinical assessments were performed by a single qualified dentist using autoclaved mouth mirror, probe, gloves, mouth mask, and portable dental operatories. Chemical sterilization (Korsolex) procedure was used to sterilize the instruments. Surface examined for a supragingival plaque of all eligible teeth are divided into mesio-facial, facial, and disto-facial, palatal or lingual surface is considered as single surface and was scored using plaque index–Sillness P and Loe H in 1964.

RINSING PROCEDURE

Using a graduated dispensing cup, the monitor measured 10 mL undiluted alum and Hi-ora mouthrinses into disposable cups (Fig. 3) and instruct the children of each group to do oral rinse by swishing 10 mL undiluted solution for 60 seconds once daily after meal. At the end of the investigation, beakers containing mouthrinses were coded according to the group and the data were decoded. The children were told not to eat/drink/rinse for 30 minutes after rinsing. A sufficient supply of mouthrinse, calibrated cups were given for the entire study period and told to continue normal oral hygiene procedures to children, except the use of mouthrinse.⁴ Following this, clinical assessments of plaque status (baseline) were done.

CLINICAL ASSESSMENTS

Plaque index: By Sillness P and Loe H in 1964.

Surface examined for a supragingival plaque of all eligible teeth are divided into mesiofacial, facial and distofacial, palatal or lingual surface is considered as single surface and was scored using plaque index–Sillness P and Loe H in 1964. The plaque was scored from 0 (no plaque) to 3 (plaque covers two-thirds or more of the tooth surface) after disclosing the teeth with erythrosine 3% solution. The same procedure was repeated at the 15th and 30th day period use of the mouthwash (Figs 4 to 6). After baseline examination, children received complete oral prophylaxis soon after receiving mouthwashes.

RESULTS

DISCUSSION

Plaque biofilm is a complex arrangement of bacteria in a self-sustaining community correlated with the initiation and progression of oral disease. Plaque preventive measures like mechanical or chemical approaches can be used in combination with this. Chemical antimicrobial agents can reach difficult to clean areas such as interproximal surfaces and can also reduce the growth of biofilms on soft tissues and as a local drug delivery agent. So, herbal and alum mouthrinse can be an alternative to other antimicrobial/antiseptic components in mouthwashes.

In the present study, a comparison with alum and herbal was done as they are the emerging components in mouthwashes and as a safe alternative to the conventional ingredients. Our study evaluated the effect of mouthwashes in plaque control in vivo. Since the main effect of mouthwash is for plaque control and indices were used to evaluate the same using a disclosing agent.

Seventy percent of the population were males and 30% were females. The mean age of the population was 10.85 years in the alum group, 10.20 years in the saline group, and 9.95 years in the herbal group (Fig. 8).

EFFECT ON PLAQUE STATUS

In the present study, we found that the mean value of plaque index scores in the alum group was found to be 1.38250 ± 0.230717 at baseline, 1.21400 ± 0.497895 on the 15th day, and 0.89250 ± 0.496640 on the 30th day. The alum mouthrinse group showed a very high statistically significant (p = 0.002) reduction in the amount of plaque on the 30th day compared to the herbal (p = 0.022) and saline group (p = 0.043). Also, a statistically significant mean difference of alum (p = 0.002), herbal (p = 0.019), and saline (p = 0.047) groups between baseline and 30th day was noticed. No statistically significant (p = 0.726) between the groups. Thus, alum mouthwash emerged as the most effective adjunctive oral hygiene measure in plaque inhibition of our study.

Alum mouthwash significantly (p %3C; 0.05) reduced the amount of plaque after 2 and 4 weeks, the mean value of plaque index scores in alum group was 1.58 ± 0.11 at 4 weeks in a study conducted by Putt et al.¹¹ Another study by Shetty et al. showed no statistically significant (p %3E; 0.5) changes between the groups (Herbal Hi-ora and Chlorhexidine mouthwash) in plaque index scores at the end of 5 days.²⁰

Siddeshappa et al. conducted a randomized clinical trial for a period of 21 days showed a statistically significant reduction in clinical and microbiological parameters with the use of herbal, chlorine dioxide mouthwashes and concluded that herbal mouthwash was statistically efficacious in controlling plaque and gingivitis with potent antimicrobial activity.²¹

In contrast to our study, Al-Bayaty et al. showed a statistically highly significant difference (p < 0.001) in plaque index scores between the groups (herbal Salvadora persica and placebo mouthrinse).²² Another study conducted by Bajaj showed a significant difference (p = 0.001) in plaque scores from baseline to the end of 9 months between the groups (herbal triphala and chlorhexidine).²³ A similar study conducted by Aspalli found that a highly significant (p < 0.0001) reduction in plaque scores between the groups (herbal hi-ora and non-herbal mouthwash).²⁴ The effect of daily supervised rinsing of alum containing mouthrinse in existing plaque and gingivitis in children is determined by Putt, Kleber, Smith et al.’s study. It is known that, due to natural astringency, alum solutions can be formulated into a compatible, palatable mouthrinse use.^25,26 Amount of plaque significantly (p < 0.05) reduced by daily use of mouthrinse containing 0.02 M alum for 30 seconds relative to the placebo. No adverse effects were observed in the oral cavity after using the alum mouthwash for 4 weeks and were accepted by the children who participated in the study.¹² In addition, long-term studies need to be conducted to determine the effect of mouthwash on oral health.

CONCLUSION

From the present study, the following conclusions were drawn:

• The study demonstrated that alum-containing mouthwash and herbal mouthwash improve plaque inhibition.
• Alum containing mouthwash (group I) and herbal mouthwash (group III) showed a statistically significant reduction in plaque index scores at baseline, 15th day, and 30th day.
• Ingredients in the alum oral rinse were effective in reducing plaque status. Hence, it may serve as an alternative antimicrobial mouthwash.
• Further long-term study with a large population group is recommended to determine the efficacy of alum-containing mouthwashes and herbal (Hi-ora) mouthwashes in improving oral health status.

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